Provider Demographics
NPI:1699757377
Name:PROVIDENCE CARE CENTER
Entity type:Organization
Organization Name:PROVIDENCE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENICE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:419-627-2273
Mailing Address - Street 1:2025 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4739
Mailing Address - Country:US
Mailing Address - Phone:419-627-2273
Mailing Address - Fax:419-627-5588
Practice Address - Street 1:2025 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4739
Practice Address - Country:US
Practice Address - Phone:419-627-2273
Practice Address - Fax:419-627-5588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4460314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000312181OtherANTHEM PROVIDER NUMBER
OH0860064Medicaid
OH365976Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
OH0860064Medicaid