Provider Demographics
NPI:1659316586
Name:MANOR CARE OF WILLOUGHBY OH, LLC
Entity Type:Organization
Organization Name:MANOR CARE OF WILLOUGHBY OH, LLC
Other - Org Name:PROMEDICA SKILLED NURSING AND REHABILITATION (WILLOUGHBY)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-252-5734
Mailing Address - Street 1:333 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:419-252-5734
Mailing Address - Fax:877-385-9446
Practice Address - Street 1:37603 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-5923
Practice Address - Country:US
Practice Address - Phone:440-951-5551
Practice Address - Fax:440-951-1914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1556N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2792312Medicaid
OH365305Medicare Oscar/Certification