Provider Demographics
NPI:1275537268
Name:PALM CREST BELLAIRE,INC.
Entity Type:Organization
Organization Name:PALM CREST BELLAIRE,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:440-239-4300
Mailing Address - Street 1:12709 BELLAIRE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-4821
Mailing Address - Country:US
Mailing Address - Phone:216-941-4545
Mailing Address - Fax:216-941-6640
Practice Address - Street 1:12709 BELLAIRE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-4821
Practice Address - Country:US
Practice Address - Phone:216-941-4545
Practice Address - Fax:216-941-6640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3892314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0350721Medicaid
OH0350721Medicaid