Provider Demographics
NPI:1144241324
Name:THE OHIO MASONIC HOME
Entity Type:Organization
Organization Name:THE OHIO MASONIC HOME
Other - Org Name:WESTERN RESERVE MASONIC COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-525-4975
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45501-0120
Mailing Address - Country:US
Mailing Address - Phone:937-525-3048
Mailing Address - Fax:937-525-8302
Practice Address - Street 1:4931 NETTLETON RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3232
Practice Address - Country:US
Practice Address - Phone:330-721-3000
Practice Address - Fax:330-721-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6114310400000X
OH6113314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2294093Medicaid
OH366240Medicare ID - Type UnspecifiedPROVIDER NUMBER