Provider Demographics
NPI:1063652139
Name:ST. AUGUSTINE MANOR CORP.
Entity Type:Organization
Organization Name:ST. AUGUSTINE MANOR CORP.
Other - Org Name:ST. AUGUSTINE TOWERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GERRASCH
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:216-634-7437
Mailing Address - Street 1:7801 DETROIT AVENUE
Mailing Address - Street 2:ST. AUGUSTINE MANOR DBA ST. AUGUSTINE TOWERS
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102
Mailing Address - Country:US
Mailing Address - Phone:216-634-7444
Mailing Address - Fax:216-634-2717
Practice Address - Street 1:7821 LAKE AVENUE
Practice Address - Street 2:ST. AUGUSTINE TOWERS
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102
Practice Address - Country:US
Practice Address - Phone:216-634-7444
Practice Address - Fax:216-634-2717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2796318Medicaid