MEDICARE: PALM CREST WEST, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	3915	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508860586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM CREST WEST, INC.

Provider Business Mailing Address
First Line	:	221 WEST AVE
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-5309
Country	:	US
Telephone Number	:	440-322-2525
Fax Number	:	440-284-1051

Provider Business Practice Location Address
First Line	:	221 WEST AVE
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-5309
Country	:	US
Telephone Number	:	440-322-2525
Fax Number	:	440-284-1051

Authorized Official
Title or Position	:	CFO
Name	:	KEVIN ROTENBERRY
Credential	:	CPA
Telephone Number	:	440-239-4300

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	08/22/2020

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