Provider Demographics
NPI:1093206138
Name:JUBILEE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:JUBILEE HEALTHCARE, LLC
Other - Org Name:NORTHSHORE HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOWRER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-895-5056
Mailing Address - Street 1:24651 CENTER RIDGE RD STE 350
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5627
Mailing Address - Country:US
Mailing Address - Phone:440-895-5056
Mailing Address - Fax:440-895-5050
Practice Address - Street 1:13170 RAVENNA RD STE 200
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-7022
Practice Address - Country:US
Practice Address - Phone:844-542-6363
Practice Address - Fax:216-455-1810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0192836Medicaid