Provider Demographics
NPI:1336579069
Name:EXTENDICARE
Entity type:Organization
Organization Name:EXTENDICARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:614-432-6665
Mailing Address - Street 1:375 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:43162-1298
Mailing Address - Country:US
Mailing Address - Phone:614-879-7661
Mailing Address - Fax:614-879-7604
Practice Address - Street 1:375 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:43162-1298
Practice Address - Country:US
Practice Address - Phone:614-879-7661
Practice Address - Fax:614-879-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH9979314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility