Provider Demographics
NPI:1841689650
Name:EMBASSY GARDEN COURT LLC
Entity type:Organization
Organization Name:EMBASSY GARDEN COURT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:BERGSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-825-6622
Mailing Address - Street 1:544 ENTERPRISE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035
Mailing Address - Country:US
Mailing Address - Phone:937-825-6622
Mailing Address - Fax:
Practice Address - Street 1:4911 COVENANT HOUSE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-2007
Practice Address - Country:US
Practice Address - Phone:937-837-2651
Practice Address - Fax:937-837-5831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1515N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH365364Medicare Oscar/Certification