Provider Demographics
NPI:1942595640
Name:OTTERBEIN LEBANON RETIREMENT LIVING COMMUNITY
Entity Type:Organization
Organization Name:OTTERBEIN LEBANON RETIREMENT LIVING COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-933-5400
Mailing Address - Street 1:585 N STATE ROUTE 741
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8840
Mailing Address - Country:US
Mailing Address - Phone:513-933-5444
Mailing Address - Fax:513-932-1054
Practice Address - Street 1:580 N STATE ROUTE 741
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-8839
Practice Address - Country:US
Practice Address - Phone:513-933-5400
Practice Address - Fax:513-932-1054
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OTTERBEIN HOMES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-10
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6636331Medicaid
OH6636331Medicaid