Provider Demographics
NPI:1063409522
Name:3102 SAINT CHARLES DRIVE OPERATING COMPANY, INC.
Entity type:Organization
Organization Name:3102 SAINT CHARLES DRIVE OPERATING COMPANY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AR DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-277-0505
Mailing Address - Street 1:3102 SAINT CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-3508
Mailing Address - Country:US
Mailing Address - Phone:740-264-7161
Mailing Address - Fax:740-264-7116
Practice Address - Street 1:3102 SAINT CHARLES DR
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-3508
Practice Address - Country:US
Practice Address - Phone:740-264-7161
Practice Address - Fax:740-264-7116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1494N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2524496Medicaid
OH2524496Medicaid