Provider Demographics
NPI:1063970200
Name:TRADITIONS AT STYGLER ROAD
Entity type:Organization
Organization Name:TRADITIONS AT STYGLER ROAD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMICKELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-451-2151
Mailing Address - Street 1:2335 N BANK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-5423
Mailing Address - Country:US
Mailing Address - Phone:614-451-2151
Mailing Address - Fax:
Practice Address - Street 1:65 S WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:OH
Practice Address - Zip Code:43031-1184
Practice Address - Country:US
Practice Address - Phone:740-967-2015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRADITIONS AT STYGLER ROAD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-06
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0136299Medicaid