Provider Demographics
NPI:1720133226
Name:BRADLEY ROAD NURSING HOME, INC.
Entity Type:Organization
Organization Name:BRADLEY ROAD NURSING HOME, INC.
Other - Org Name:BRADLEY BAY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:440-871-3474
Mailing Address - Street 1:34100 CENTER RIDGE RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-5311
Mailing Address - Country:US
Mailing Address - Phone:440-327-9777
Mailing Address - Fax:440-327-6172
Practice Address - Street 1:605 BRADLEY RD
Practice Address - Street 2:
Practice Address - City:BAY VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44140-1670
Practice Address - Country:US
Practice Address - Phone:440-871-3474
Practice Address - Fax:440-871-4743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5511310400000X
OH4413314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4413OtherOHIO DEPT. OF HEALTH
OH2515148Medicaid
OH4413OtherOHIO DEPT. OF HEALTH