Provider Demographics
NPI:1629304399
Name:TRILOGY HEALTHCARE OF MONTGOMERY LLC
Entity Type:Organization
Organization Name:TRILOGY HEALTHCARE OF MONTGOMERY LLC
Other - Org Name:CYPRESS POINTE HEALTH CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP - FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:P
Authorized Official - Last Name:PLEVYAK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:502-213-1710
Mailing Address - Street 1:600 WEST NATIONAL ROAD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1162
Mailing Address - Country:US
Mailing Address - Phone:937-836-3149
Mailing Address - Fax:937-836-3158
Practice Address - Street 1:600 WEST NATIONAL ROAD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1162
Practice Address - Country:US
Practice Address - Phone:937-836-3149
Practice Address - Fax:937-836-3158
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRILOGY HEALTH SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPENDING314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3022259Medicaid
OH366384Medicare Oscar/Certification