Provider Demographics
NPI:1255596359
Name:IVY HOUSE ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:IVY HOUSE ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-354-2131
Mailing Address - Street 1:308 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3532
Mailing Address - Country:US
Mailing Address - Phone:440-354-2131
Mailing Address - Fax:440-354-2068
Practice Address - Street 1:308 S STATE ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3532
Practice Address - Country:US
Practice Address - Phone:440-354-2131
Practice Address - Fax:440-354-2068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0080R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility