Provider Demographics
NPI:1689771826
Name:CAPITAL SENIOR LIVING, ILM-B INC.
Entity Type:Organization
Organization Name:CAPITAL SENIOR LIVING, ILM-B INC.
Other - Org Name:CANTON REGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:GASPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-477-7664
Mailing Address - Street 1:4515 22ND ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-1573
Mailing Address - Country:US
Mailing Address - Phone:330-477-7664
Mailing Address - Fax:330-478-9645
Practice Address - Street 1:4515 22ND ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-1573
Practice Address - Country:US
Practice Address - Phone:330-477-7664
Practice Address - Fax:330-478-9645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5977314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000280669OtherANTHEM PROVIDER NUMBER
OH0005319462OtherAETNA PROVIDER NUMBER
OH=========OtherFEDERAL TAX ID
OH000000280669OtherANTHEM PROVIDER NUMBER