Provider Demographics
NPI:1295719771
Name:COAL GROVE LONG TERM CARE, INC
Entity type:Organization
Organization Name:COAL GROVE LONG TERM CARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC. VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHARFENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:513-793-8804
Mailing Address - Street 1:7265 KENWOOD RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-4414
Mailing Address - Country:US
Mailing Address - Phone:513-793-8804
Mailing Address - Fax:513-793-8799
Practice Address - Street 1:813 1/2 MARION PIKE
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-3070
Practice Address - Country:US
Practice Address - Phone:740-532-0449
Practice Address - Fax:740-532-7141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3734314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH8581075Medicaid
OH0632520001Medicare NSC
OH8581075Medicaid