Provider Demographics
NPI:1104662600
Name:THE COMMONS OF PROVIDENCE
Entity type:Organization
Organization Name:THE COMMONS OF PROVIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ANCILLRY CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-562-7202
Mailing Address - Street 1:5000 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-1410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-1410
Practice Address - Country:US
Practice Address - Phone:419-624-1171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility