Provider Demographics
NPI:1104861962
Name:HEARTLAND-BEAVERCREEK OF DAYTON OH, LLC
Entity Type:Organization
Organization Name:HEARTLAND-BEAVERCREEK OF DAYTON OH, LLC
Other - Org Name:PROMEDICA SKILLED NURSING AND REHABILITATION (BEAVERCREEK)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-252-5743
Mailing Address - Street 1:333 N SUMMIT ST
Mailing Address - Street 2:ATTN: MARTIN ALLEN
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:419-252-5743
Mailing Address - Fax:877-385-9446
Practice Address - Street 1:1974 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2772
Practice Address - Country:US
Practice Address - Phone:937-429-1106
Practice Address - Fax:937-429-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1653N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2791975Medicaid
OH2791975Medicaid