Provider Demographics
NPI:1154178028
Name:WALNUT CREEK AL OPCO LLC
Entity type:Organization
Organization Name:WALNUT CREEK AL OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGYANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-620-7828
Mailing Address - Street 1:5915 LANDERBROOK DR STE 350
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-4063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 KEYSTONE CLUB DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45439-4223
Practice Address - Country:US
Practice Address - Phone:330-620-7828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility