Provider Demographics
NPI:1710979141
Name:OTTERBEIN CRIDERSVILLE
Entity Type:Organization
Organization Name:OTTERBEIN CRIDERSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AVP FINANCE/CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-933-5401
Mailing Address - Street 1:100 RED OAK DR
Mailing Address - Street 2:
Mailing Address - City:CRIDERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45806-9618
Mailing Address - Country:US
Mailing Address - Phone:419-645-5114
Mailing Address - Fax:419-645-7115
Practice Address - Street 1:100 RED OAK DR
Practice Address - Street 2:
Practice Address - City:CRIDERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45806-9618
Practice Address - Country:US
Practice Address - Phone:419-645-5114
Practice Address - Fax:419-645-7115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1959N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0228088Medicaid
4488240001OtherDMERC
4488240001OtherDMERC