Provider Demographics
NPI:1003939786
Name:OTTERBEIN PERRYSBURG LLC
Entity Type:Organization
Organization Name:OTTERBEIN PERRYSBURG LLC
Other - Org Name:AVALON BY OTTERBEIN PERRYSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER & CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:513-933-5418
Mailing Address - Street 1:580 N STATE ROUTE 741
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8839
Mailing Address - Country:US
Mailing Address - Phone:513-932-5401
Mailing Address - Fax:513-932-1054
Practice Address - Street 1:3529 RIVERS EDGE DRIVE
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551
Practice Address - Country:US
Practice Address - Phone:419-874-2428
Practice Address - Fax:419-872-8464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2480N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2768107Medicaid
OH366354Medicare Oscar/Certification