Provider Demographics
NPI:1942890306
Name:DUBLIN CONVALARIUM OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:DUBLIN CONVALARIUM OPERATING COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-499-3311
Mailing Address - Street 1:6430 POST RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-1226
Mailing Address - Country:US
Mailing Address - Phone:614-761-1188
Mailing Address - Fax:
Practice Address - Street 1:6430 POST RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-1226
Practice Address - Country:US
Practice Address - Phone:614-761-1188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1900ROtherLICENSURE