Provider Demographics
NPI:1235128034
Name:ST. AUGUSTINE SERVICES CORP.
Entity Type:Organization
Organization Name:ST. AUGUSTINE SERVICES CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:EDMUNA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:216-634-7440
Mailing Address - Street 1:7801 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-2813
Mailing Address - Country:US
Mailing Address - Phone:216-634-7425
Mailing Address - Fax:
Practice Address - Street 1:7801 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-2813
Practice Address - Country:US
Practice Address - Phone:216-634-7425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4654314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0764249Medicaid
OH0852162Medicaid
OH0852162Medicaid