Provider Demographics
NPI:1245227941
Name:STEUBENVILLE COUNTRY CLUB MANOR
Entity Type:Organization
Organization Name:STEUBENVILLE COUNTRY CLUB MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOLGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-266-6118
Mailing Address - Street 1:575 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43953-3311
Mailing Address - Country:US
Mailing Address - Phone:740-266-6118
Mailing Address - Fax:740-264-8898
Practice Address - Street 1:575 LOVERS LN
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43953-3311
Practice Address - Country:US
Practice Address - Phone:740-266-6118
Practice Address - Fax:740-264-8898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6136314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2314650Medicaid
OH366241Medicare ID - Type Unspecified