Provider Demographics
NPI:1962510305
Name:THE OHIO MASONIC HOME
Entity Type:Organization
Organization Name:THE OHIO MASONIC HOME
Other - Org Name:SPRINGFIELD MASONIC COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-525-4975
Mailing Address - Street 1:3 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-3658
Mailing Address - Country:US
Mailing Address - Phone:937-325-1531
Mailing Address - Fax:937-525-8291
Practice Address - Street 1:3 MASONIC DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-3658
Practice Address - Country:US
Practice Address - Phone:937-325-1531
Practice Address - Fax:937-525-8291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5208314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000002797OtherANTHEM
OH2005850Medicaid
OH2005850Medicaid