MEDICARE: DEACONESS LONG TERM CARE OF OHIO, 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	310400000X	Assisted Living Facility	031471	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	031471	OTHER	MO	STATE LICENSE #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578557369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEACONESS LONG TERM CARE OF OHIO, INC.

Provider Business Mailing Address
First Line	:	440 LAFAYETTE AVE
Second Line	:	SUITE 400
City	:	CINCINNATI
State	:	OH
Zip	:	45220-1022
Country	:	US
Telephone Number	:	513-487-3600
Fax Number	:	513-487-3653

Provider Business Practice Location Address
First Line	:	1000 NW THIRD ST
Second Line	:
City	:	AVA
State	:	MO
Zip	:	65608
Country	:	US
Telephone Number	:	417-683-6999
Fax Number	:	417-683-6195

Authorized Official
Title or Position	:	CFO
Name	:	CARLA BROOKS
Credential	:
Telephone Number	:	513-487-3600

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	06/27/2008

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