Provider Demographics
NPI:1508340571
Name:CLOVERNOOK HEALTHCARE LLC
Entity Type:Organization
Organization Name:CLOVERNOOK HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-659-1353
Mailing Address - Street 1:15 AMERICA AVE UNIT 304
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4582
Mailing Address - Country:US
Mailing Address - Phone:732-659-1353
Mailing Address - Fax:
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:513-522-4122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1743NOtherLICENSURE