Provider Demographics
NPI:1346248804
Name:LINCOLN PARK ASSOCIATES II LTD PTR
Entity Type:Organization
Organization Name:LINCOLN PARK ASSOCIATES II LTD PTR
Other - Org Name:LINCOLN PARK MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-588-4748
Mailing Address - Street 1:694 ISAAC PRUGH WAY
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3481
Mailing Address - Country:US
Mailing Address - Phone:937-297-4300
Mailing Address - Fax:937-297-4199
Practice Address - Street 1:694 ISAAC PRUGH WAY
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3481
Practice Address - Country:US
Practice Address - Phone:937-297-4300
Practice Address - Fax:937-297-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1915R310400000X
OH1915N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
365773Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER