Provider Demographics
NPI:1427081629
Name:GLENDALE PLACE CARE CENTER LLC
Entity type:Organization
Organization Name:GLENDALE PLACE CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHASE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-771-1779
Mailing Address - Street 1:779 GLENDALE MILFORD RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-1161
Mailing Address - Country:US
Mailing Address - Phone:513-771-1779
Mailing Address - Fax:513-771-4799
Practice Address - Street 1:779 GLENDALE MILFORD RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-1161
Practice Address - Country:US
Practice Address - Phone:513-771-1779
Practice Address - Fax:513-771-4799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2450N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2675645Medicaid
OH366327Medicare Oscar/Certification