Provider Demographics
NPI:1861504961
Name:115 ELMWOOD CIRCLE OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:115 ELMWOOD CIRCLE OPERATING COMPANY, LLC
Other - Org Name:WEST CARROLTON HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT - CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRESLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-242-4000
Mailing Address - Street 1:115 ELMWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 ELMWOOD CIR
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2428
Practice Address - Country:US
Practice Address - Phone:937-866-3814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
36-5598Medicare ID - Type Unspecified