Provider Demographics
NPI:1629264379
Name:PEREGRINE SERVICES OF CANTON, LLC
Entity Type:Organization
Organization Name:PEREGRINE SERVICES OF CANTON, LLC
Other - Org Name:SUMMIT'STRACE OF CANTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAUERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-459-2656
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 1:836 34TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-2947
Practice Address - Country:US
Practice Address - Phone:614-459-2482
Practice Address - Fax:614-459-2641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2771095Medicaid
OH2771095Medicaid