Provider Demographics
NPI:1295009710
Name:ST. LUKE LUTHERAN COMMUNITY-MINERVA
Entity Type:Organization
Organization Name:ST. LUKE LUTHERAN COMMUNITY-MINERVA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:DERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-966-5619
Mailing Address - Street 1:220 APPLEGROVE ST NE
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-1610
Mailing Address - Country:US
Mailing Address - Phone:330-499-8341
Mailing Address - Fax:330-497-6141
Practice Address - Street 1:4301 WOODALE AVE SE
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-8923
Practice Address - Country:US
Practice Address - Phone:330-499-8341
Practice Address - Fax:330-497-6141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility