Provider Demographics
NPI:1275719049
Name:BLANCHARD VALLEY CONTINUING CARE SERVICES
Entity Type:Organization
Organization Name:BLANCHARD VALLEY CONTINUING CARE SERVICES
Other - Org Name:INDEPENDENCE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRIDGETT
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:419-435-8505
Mailing Address - Street 1:1000 INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-9614
Mailing Address - Country:US
Mailing Address - Phone:419-435-8505
Mailing Address - Fax:
Practice Address - Street 1:1000 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-9614
Practice Address - Country:US
Practice Address - Phone:419-435-8505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLANCHARD VALLEY HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-11
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4444313M00000X
OH1951N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2789791Medicaid
OH365860Medicare PIN