Provider Demographics
NPI:1457848210
Name:CT OHIO PORTSMOUTH LLC
Entity type:Organization
Organization Name:CT OHIO PORTSMOUTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-865-1500
Mailing Address - Street 1:727 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-4020
Mailing Address - Country:US
Mailing Address - Phone:740-354-8150
Mailing Address - Fax:
Practice Address - Street 1:727 8TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4020
Practice Address - Country:US
Practice Address - Phone:740-354-8150
Practice Address - Fax:740-353-1826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH141343Medicaid