Provider Demographics
NPI:1376690461
Name:SHELBY COUNTY OHIO
Entity Type:Organization
Organization Name:SHELBY COUNTY OHIO
Other - Org Name:FAIR HAVEN SHELBY COUNTY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:937-492-6900
Mailing Address - Street 1:2901 FAIR RD
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-9534
Mailing Address - Country:US
Mailing Address - Phone:937-492-6900
Mailing Address - Fax:
Practice Address - Street 1:2901 FAIR RD
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-9534
Practice Address - Country:US
Practice Address - Phone:937-492-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHELBY COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-04
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0270111Medicaid
OH0270111Medicaid