Provider Demographics
NPI:1083618060
Name:ELY PARK HEALTH CARE, INC.
Entity type:Organization
Organization Name:ELY PARK HEALTH CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLERAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-614-0160
Mailing Address - Street 1:22021 BROOKPARK RD
Mailing Address - Street 2:SUITE 123
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3100
Mailing Address - Country:US
Mailing Address - Phone:440-614-0160
Mailing Address - Fax:440-614-0168
Practice Address - Street 1:1251 EAST AVE
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-7674
Practice Address - Country:US
Practice Address - Phone:440-322-0726
Practice Address - Fax:440-322-2810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4023314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2750670Medicaid
OH2750670Medicaid