Provider Demographics
NPI:1487636452
Name:MICAH CLOVERNOOK
Entity Type:Organization
Organization Name:MICAH CLOVERNOOK
Other - Org Name:CLOVERNOOK HEALTH CARE PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-605-2700
Mailing Address - Street 1:12500 REED HARTMAN HIGHWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231
Mailing Address - Country:US
Mailing Address - Phone:513-605-2700
Mailing Address - Fax:513-605-2798
Practice Address - Street 1:7025 CLOVERNOOK AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-5557
Practice Address - Country:US
Practice Address - Phone:513-605-4000
Practice Address - Fax:513-605-2798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1743N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2313900Medicaid
OH365551Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER