Provider Demographics
NPI:1780613794
Name:LUTHERAN MEMORIAL HOME
Entity type:Organization
Organization Name:LUTHERAN MEMORIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHURTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-861-4990
Mailing Address - Street 1:2021 N MCCORD RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-3030
Mailing Address - Country:US
Mailing Address - Phone:419-861-4990
Mailing Address - Fax:419-861-2710
Practice Address - Street 1:795 BARDSHAR RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-1505
Practice Address - Country:US
Practice Address - Phone:419-625-4046
Practice Address - Fax:419-625-0821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN HOMES SOCIETY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2854314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3780707OtherCIGNA
OH000000283851OtherANTHEM BC/BS
OH2134381Medicaid
OH=========-00OtherBUREAU WORKERS COMP
OH2134381Medicaid
OH366219Medicare ID - Type Unspecified