Provider Demographics
NPI:1598852782
Name:THI OF OHIO AT IMPERIAL, LLC
Entity Type:Organization
Organization Name:THI OF OHIO AT IMPERIAL, LLC
Other - Org Name:IMPERIAL SKILLED CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-898-3702
Mailing Address - Street 1:930 RIDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9390
Mailing Address - Country:US
Mailing Address - Phone:410-773-1000
Mailing Address - Fax:
Practice Address - Street 1:4121 TOD AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-1258
Practice Address - Country:US
Practice Address - Phone:330-898-3702
Practice Address - Fax:330-898-6280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2410877Medicaid
365034Medicare Oscar/Certification