MEDICARE: BCC ONTARIO OPERATIONS LLC

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	2205R	OH

General Provider Information

NPI Number	:	1861633547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BCC ONTARIO OPERATIONS LLC

Provider Business Mailing Address
First Line	:	9510 ORMSBY STATION RD
Second Line	:	SUITE 101
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-4081
Country	:	US
Telephone Number	:	502-753-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2010 WALKER LAKE RD
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-1412
Country	:	US
Telephone Number	:	419-747-1119
Fax Number	:	419-747-4887

Authorized Official
Title or Position	:	CEO
Name	:	MR. WILLIAM P MULLOY II
Credential	:
Telephone Number	:	502-753-6000

Provider Enumeration Date	:	03/10/2009
Last Update Date	:	03/10/2009

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