Provider Demographics
NPI:1306870738
Name:WAYSIDE FARM INC.
Entity type:Organization
Organization Name:WAYSIDE FARM INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:W
Authorized Official - Last Name:POOL
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:330-923-7828
Mailing Address - Street 1:4557 QUICK RD
Mailing Address - Street 2:
Mailing Address - City:PENINSULA
Mailing Address - State:OH
Mailing Address - Zip Code:44264-9794
Mailing Address - Country:US
Mailing Address - Phone:330-923-7828
Mailing Address - Fax:330-923-1201
Practice Address - Street 1:4557 QUICK RD
Practice Address - Street 2:
Practice Address - City:PENINSULA
Practice Address - State:OH
Practice Address - Zip Code:44264-9708
Practice Address - Country:US
Practice Address - Phone:330-923-7828
Practice Address - Fax:330-923-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1279313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0040879Medicaid
OH366323Medicare ID - Type UnspecifiedMEDICARE