Provider Demographics
NPI:1598968570
Name:ELIZA JENNINGS SERVICES CORPORATION
Entity Type:Organization
Organization Name:ELIZA JENNINGS SERVICES CORPORATION
Other - Org Name:ACACIA PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF CLINICAL SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:216-226-5000
Mailing Address - Street 1:10603 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-1647
Mailing Address - Country:US
Mailing Address - Phone:216-226-6090
Mailing Address - Fax:
Practice Address - Street 1:10603 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-1647
Practice Address - Country:US
Practice Address - Phone:216-226-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2623610Medicaid