Provider Demographics
NPI:1740307784
Name:GIBSONBURG HEALTH, LLC
Entity type:Organization
Organization Name:GIBSONBURG HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:419-637-2104
Mailing Address - Street 1:355 WINDSOR LN
Mailing Address - Street 2:
Mailing Address - City:GIBSONBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43431-1446
Mailing Address - Country:US
Mailing Address - Phone:419-637-2104
Mailing Address - Fax:419-637-2555
Practice Address - Street 1:355 WINDSOR LN
Practice Address - Street 2:
Practice Address - City:GIBSONBURG
Practice Address - State:OH
Practice Address - Zip Code:43431-1446
Practice Address - Country:US
Practice Address - Phone:419-637-2104
Practice Address - Fax:419-637-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1850314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2571908Medicaid
OH2571908Medicaid