Provider Demographics
NPI:1043207038
Name:CARRIAGE INN OF BOWERSTON INC
Entity Type:Organization
Organization Name:CARRIAGE INN OF BOWERSTON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE AR DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-277-0505
Mailing Address - Street 1:102 BOYCE DR
Mailing Address - Street 2:P.O. BOX 261
Mailing Address - City:BOWERSTON
Mailing Address - State:OH
Mailing Address - Zip Code:44695-9701
Mailing Address - Country:US
Mailing Address - Phone:740-269-8001
Mailing Address - Fax:740-269-1733
Practice Address - Street 1:102 BOYCE DR
Practice Address - Street 2:
Practice Address - City:BOWERSTON
Practice Address - State:OH
Practice Address - Zip Code:44695-9701
Practice Address - Country:US
Practice Address - Phone:740-269-8001
Practice Address - Fax:740-269-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5964313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2283998Medicaid
OH366249Medicare ID - Type UnspecifiedPROVIDER NUMBER