Provider Demographics
NPI:1235563701
Name:NA
Entity Type:Organization
Organization Name:NA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STNA
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-939-9789
Mailing Address - Street 1:3385 GREENWICH DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5322
Mailing Address - Country:US
Mailing Address - Phone:513-939-9789
Mailing Address - Fax:
Practice Address - Street 1:3385 GREENWICH DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5322
Practice Address - Country:US
Practice Address - Phone:513-939-9789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-02
Last Update Date:2013-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401253500611313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility