Provider Demographics
NPI:1629665146
Name:ST. LUKE LUTHERAN COMMUNITY - PORTAGE LAKES
Entity Type:Organization
Organization Name:ST. LUKE LUTHERAN COMMUNITY - PORTAGE LAKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-499-8341
Mailing Address - Street 1:220 APPLEGROVE ST NE
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-1610
Mailing Address - Country:US
Mailing Address - Phone:330-499-8341
Mailing Address - Fax:330-497-6141
Practice Address - Street 1:615 LATHAM LN
Practice Address - Street 2:
Practice Address - City:NEW FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:44319-4338
Practice Address - Country:US
Practice Address - Phone:330-644-3914
Practice Address - Fax:330-644-8966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. LUKE LUTHERAN COMMUNITY - PORTAGE LAKES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2444797Medicaid