Provider Demographics
NPI:1588803985
Name:PEREGRINE HEALTH SERVICES OF COLUMBUS LLC
Entity Type:Organization
Organization Name:PEREGRINE HEALTH SERVICES OF COLUMBUS LLC
Other - Org Name:SUMMIT'S TRACE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-459-2482
Mailing Address - Street 1:1661 OLD HENDERSON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3644
Mailing Address - Country:US
Mailing Address - Phone:614-459-2656
Mailing Address - Fax:614-459-2641
Practice Address - Street 1:935 N CASSADY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-2283
Practice Address - Country:US
Practice Address - Phone:614-252-4987
Practice Address - Fax:614-252-5952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
OH1061N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2920530Medicaid
OH2912978Medicaid