Provider Demographics
NPI:1881023885
Name:KETTERING AFFILIATED HEALTH SERVICES
Entity Type:Organization
Organization Name:KETTERING AFFILIATED HEALTH SERVICES
Other - Org Name:SYCAMORE GLEN RETIREMENT COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EX VICE PRESIDENT, CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEWHIRTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-395-8994
Mailing Address - Street 1:317 SYCAMORE GLEN DR
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5720
Mailing Address - Country:US
Mailing Address - Phone:937-866-2984
Mailing Address - Fax:937-866-7488
Practice Address - Street 1:317 SYCAMORE GLEN DR
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-5720
Practice Address - Country:US
Practice Address - Phone:937-866-2984
Practice Address - Fax:937-866-7488
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETTERING AFFILIATED HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-11
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1876R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2676886Medicaid