Provider Demographics
NPI:1093744104
Name:LIBERTY NURSING CENTER OF WILLARD INC
Entity Type:Organization
Organization Name:LIBERTY NURSING CENTER OF WILLARD INC
Other - Org Name:HILLSIDE ACRES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK-KUREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-296-1550
Mailing Address - Street 1:7445 LIBERTY WOODS LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3911
Mailing Address - Country:US
Mailing Address - Phone:937-296-1550
Mailing Address - Fax:937-296-1540
Practice Address - Street 1:370 E HOWARD ST
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-1656
Practice Address - Country:US
Practice Address - Phone:419-935-0148
Practice Address - Fax:419-933-6448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH60153140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2245010Medicaid
OH2245010Medicaid