Provider Demographics
NPI:1043201379
Name:CONCORD CARE CENTER OF SANDUSKY, INC.
Entity Type:Organization
Organization Name:CONCORD CARE CENTER OF SANDUSKY, INC.
Other - Org Name:CONCORD CARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:IFFT
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:330-759-2357
Mailing Address - Street 1:620 W STRUB RD
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5779
Mailing Address - Country:US
Mailing Address - Phone:419-626-5373
Mailing Address - Fax:419-627-1181
Practice Address - Street 1:620 W STRUB RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5779
Practice Address - Country:US
Practice Address - Phone:419-626-5373
Practice Address - Fax:419-627-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5642314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1760566343OtherMEDICARE DME NPI
OH2109551Medicaid
OH000000250271OtherANTHEM
OH000000250271OtherANTHEM
OH365885Medicare ID - Type UnspecifiedPROVIDER NUMBER
OH365885Medicare PIN