Provider Demographics
NPI:1669471264
Name:THE OHIO EASTERN STAR HOME, INC
Entity Type:Organization
Organization Name:THE OHIO EASTERN STAR HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZANDRA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:740-397-1706
Mailing Address - Street 1:1451 GAMBIER RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-9112
Mailing Address - Country:US
Mailing Address - Phone:740-397-1706
Mailing Address - Fax:740-392-1662
Practice Address - Street 1:1451 GAMBIER RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9112
Practice Address - Country:US
Practice Address - Phone:740-397-1706
Practice Address - Fax:740-392-1662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH190313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1037OtherHOME NUMBER