Provider Demographics
NPI:1417079021
Name:PEARL III LEASING CO, LLC
Entity Type:Organization
Organization Name:PEARL III LEASING CO, LLC
Other - Org Name:PINE GROVE HABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF A/R
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-530-1327
Mailing Address - Street 1:4700 ASHWOOD DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2465
Mailing Address - Country:US
Mailing Address - Phone:513-530-1600
Mailing Address - Fax:513-530-1697
Practice Address - Street 1:5608 PEARL RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-2547
Practice Address - Country:US
Practice Address - Phone:440-888-1320
Practice Address - Fax:440-888-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH25454315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2607129Medicaid