Provider Demographics
NPI:1821018649
Name:MANSFIELD MEMORIAL HOMES, INC
Entity Type:Organization
Organization Name:MANSFIELD MEMORIAL HOMES, INC
Other - Org Name:GERIATRIC CENTER OF MANSFIELD
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUGHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-774-5120
Mailing Address - Street 1:50 BLYMYER AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2343
Mailing Address - Country:US
Mailing Address - Phone:419-774-5120
Mailing Address - Fax:419-524-7537
Practice Address - Street 1:50 BLYMYER AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2343
Practice Address - Country:US
Practice Address - Phone:419-774-5120
Practice Address - Fax:419-524-7537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH064501314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5489850Medicaid
OH=========Medicare UPIN
OH365118Medicare ID - Type Unspecified