Provider Demographics
NPI:1356603245
Name:COVENANT VILLAGE OF GREEN TOWNSHIP, LLC
Entity type:Organization
Organization Name:COVENANT VILLAGE OF GREEN TOWNSHIP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-605-2701
Mailing Address - Street 1:12500 REED HARTMAN HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-1892
Mailing Address - Country:US
Mailing Address - Phone:513-605-2700
Mailing Address - Fax:
Practice Address - Street 1:3210 W FORK RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-1948
Practice Address - Country:US
Practice Address - Phone:513-605-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2616N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0073645Medicaid
OH366399Medicare PIN