Provider Demographics
NPI:1568446862
Name:CHS - LAKE ERIE, INC
Entity Type:Organization
Organization Name:CHS - LAKE ERIE, INC
Other - Org Name:BRYDEN PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLERAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-614-0160
Mailing Address - Street 1:25000 COUNTRY CLUB BLVD
Mailing Address - Street 2:SUITE 255
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-5344
Mailing Address - Country:US
Mailing Address - Phone:440-614-0160
Mailing Address - Fax:440-614-0168
Practice Address - Street 1:1169 BRYDEN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1928
Practice Address - Country:US
Practice Address - Phone:614-258-6623
Practice Address - Fax:614-258-8171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6254314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2339599Medicaid
OH2339599Medicaid