Provider Demographics
NPI:1851497986
Name:PORTAGE TRAIL CARE CENTER, INC
Entity Type:Organization
Organization Name:PORTAGE TRAIL CARE CENTER, INC
Other - Org Name:NATIONAL CHURCH RESIDENCES BATH ROAD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMICKELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-451-2151
Mailing Address - Street 1:2335 N BANK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-5423
Mailing Address - Country:US
Mailing Address - Phone:614-451-2151
Mailing Address - Fax:
Practice Address - Street 1:45 CATHEDRAL LN
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-1657
Practice Address - Country:US
Practice Address - Phone:330-928-7530
Practice Address - Fax:330-945-3404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
OH4373314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2588ROtherRESIDENTIAL CARE FACILITY LICENSE
OH3149828Medicaid
365826Medicare ID - Type UnspecifiedMEDICARE