Provider Demographics
NPI:1205189313
Name:PROGRESSIVE MEDINA LLC
Entity Type:Organization
Organization Name:PROGRESSIVE MEDINA LLC
Other - Org Name:AVENUE AT MEDINA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:EITAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FLANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-684-9220
Mailing Address - Street 1:5553 BROADVIEW RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-1604
Mailing Address - Country:US
Mailing Address - Phone:216-661-6800
Mailing Address - Fax:216-739-3789
Practice Address - Street 1:699 E SMITH RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2639
Practice Address - Country:US
Practice Address - Phone:216-661-6800
Practice Address - Fax:216-739-3789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0080055Medicaid
OH366407Medicare Oscar/Certification