Provider Demographics
NPI:1255188124
Name:LAKEWOOD SENIOR CAMPUS, LLC
Entity type:Organization
Organization Name:LAKEWOOD SENIOR CAMPUS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:400-387-5555
Mailing Address - Street 1:38642 CENTER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-5812
Mailing Address - Country:US
Mailing Address - Phone:440-387-5500
Mailing Address - Fax:440-327-6172
Practice Address - Street 1:13900 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4624
Practice Address - Country:US
Practice Address - Phone:216-228-7650
Practice Address - Fax:216-228-7655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKEWOOD SENIOR CAMPUS, LLC
Parent Organization TIN:<UNAVAIL>
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2887005Medicaid