Provider Demographics
NPI:1376533877
Name:HEATHER KNOLL RETIREMENT VILLAGE INC
Entity Type:Organization
Organization Name:HEATHER KNOLL RETIREMENT VILLAGE INC
Other - Org Name:HEATHER KNOLL OF SUMMIT COUNTY
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VP AND CIO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SPRENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-989-5234
Mailing Address - Street 1:1134 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1065
Mailing Address - Country:US
Mailing Address - Phone:330-688-8600
Mailing Address - Fax:330-688-8495
Practice Address - Street 1:1134 NORTH AVE
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-1065
Practice Address - Country:US
Practice Address - Phone:330-688-8600
Practice Address - Fax:330-688-8495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5582314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341904757003OtherMEDICAL MUTUAL
OH2590352Medicaid
BC000000M89OtherANTHEM
BC000000M89OtherANTHEM
OH341904757003OtherMEDICAL MUTUAL