MEDICARE: LEGACY PLACE TWINSBURG,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
2	314000000X	Skilled Nursing Facility	1002990	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	:	1932435799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY PLACE TWINSBURG,LLC

Provider Business Mailing Address
First Line	:	12380 PLAZA DR
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44130-1043
Country	:	US
Telephone Number	:	216-898-8399
Fax Number	:	216-898-8455

Provider Business Practice Location Address
First Line	:	9928 VAIL DR
Second Line	:
City	:	TWINSBURG
State	:	OH
Zip	:	44087-2972
Country	:	US
Telephone Number	:	216-898-8399
Fax Number	:	216-898-8455

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BRUCE DASKAL
Credential	:
Telephone Number	:	216-898-8399

Provider Enumeration Date	:	10/28/2009
Last Update Date	:	05/06/2010

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