Provider Demographics
NPI:1508865767
Name:GASLITE VILLA CONVALESCENT CENTER, INC.
Entity Type:Organization
Organization Name:GASLITE VILLA CONVALESCENT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CORITA
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:330-854-4545
Mailing Address - Street 1:7055 HIGH MILL AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANAL FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:44614-9344
Mailing Address - Country:US
Mailing Address - Phone:330-854-4545
Mailing Address - Fax:330-854-6319
Practice Address - Street 1:7055 HIGH MILL AVE NW
Practice Address - Street 2:
Practice Address - City:CANAL FULTON
Practice Address - State:OH
Practice Address - Zip Code:44614-9344
Practice Address - Country:US
Practice Address - Phone:330-854-4545
Practice Address - Fax:330-854-6319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH001063N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3089803Medicaid
OH366271Medicare ID - Type Unspecified