Provider Demographics
NPI:1578645214
Name:RESTHAVEN OPERATIONS LLC
Entity Type:Organization
Organization Name:RESTHAVEN OPERATIONS LLC
Other - Org Name:REST HAVEN NURSING HOME VANCREST OF GREENVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO SHAREHOLDER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:MCCLEERY
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:419-238-0715
Mailing Address - Street 1:1096 NORTH OHIO STREET
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331
Mailing Address - Country:US
Mailing Address - Phone:937-548-1138
Mailing Address - Fax:
Practice Address - Street 1:1096 NORTH OHIO STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331
Practice Address - Country:US
Practice Address - Phone:937-548-1138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REST HAVEN NURSING HOME INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-20
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1467314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2472622Medicaid
OH000000002692OtherANTHEM BCBS
OH365448Medicare UPIN
OH000000002692OtherANTHEM BCBS