Provider Demographics
NPI:1750521001
Name:WADSWORTH ALF
Entity type:Organization
Organization Name:WADSWORTH ALF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:S
Authorized Official - Last Name:BALASCOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-333-2132
Mailing Address - Street 1:540 GREAT OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8799
Mailing Address - Country:US
Mailing Address - Phone:330-336-3472
Mailing Address - Fax:330-334-0647
Practice Address - Street 1:540 GREAT OAKS TRL
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-8799
Practice Address - Country:US
Practice Address - Phone:330-336-3472
Practice Address - Fax:330-334-0647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2059R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2733573Medicaid