Provider Demographics
NPI:1851068761
Name:EMBASSY PAINESVILLE, LLC
Entity Type:Organization
Organization Name:EMBASSY PAINESVILLE, LLC
Other - Org Name:EMBASSY OF PAINESVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CICCONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-378-2050
Mailing Address - Street 1:25201 CHAGRIN BLVD STE 190
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5633
Mailing Address - Country:US
Mailing Address - Phone:216-378-2050
Mailing Address - Fax:
Practice Address - Street 1:70 NORMANDY DR
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-1616
Practice Address - Country:US
Practice Address - Phone:440-357-1311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-27
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1874NOtherLICENSURE