Provider Demographics
NPI:1073100681
Name:THE LODGE ACTIVITY CENTER LLC,
Entity Type:Organization
Organization Name:THE LODGE ACTIVITY CENTER LLC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CELENA
Authorized Official - Middle Name:V
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-291-0974
Mailing Address - Street 1:654 HISTORY BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-3660
Mailing Address - Country:US
Mailing Address - Phone:513-291-0974
Mailing Address - Fax:
Practice Address - Street 1:1390 EATON AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-1407
Practice Address - Country:US
Practice Address - Phone:513-291-0974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care