Provider Demographics
NPI:1013908334
Name:CONCORD CARE CENTER OF CORTLAND, INC.
Entity Type:Organization
Organization Name:CONCORD CARE CENTER OF CORTLAND, INC.
Other - Org Name:BRIARFIELD OF CORTLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:IFFT
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:330-759-2357
Mailing Address - Street 1:4250 SODOM HUTCHINGS RD
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-9790
Mailing Address - Country:US
Mailing Address - Phone:330-637-7906
Mailing Address - Fax:330-638-2639
Practice Address - Street 1:4250 SODOM HUTCHINGS RD
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-9790
Practice Address - Country:US
Practice Address - Phone:330-637-7906
Practice Address - Fax:330-638-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5644314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2109695Medicaid
OH1689750895OtherMEDICARE DME SUPPLIER NUM
OH000000346687OtherANTHEM
OH1275760001Medicare NSC
OH365949Medicare PIN
OH2109695Medicaid