Provider Demographics
NPI:1720203698
Name:CREEKSIDE AT THE VILLAGE
Entity Type:Organization
Organization Name:CREEKSIDE AT THE VILLAGE
Other - Org Name:WEXNER HERITAGE VILLAGE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:614-559-0304
Mailing Address - Street 1:2200 WELCOME PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-2964
Mailing Address - Country:US
Mailing Address - Phone:614-559-5500
Mailing Address - Fax:614-559-5638
Practice Address - Street 1:2200 WELCOME PL
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-2964
Practice Address - Country:US
Practice Address - Phone:614-559-5500
Practice Address - Fax:614-559-5638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2432R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherEMPLOYER ID NUMBER