Provider Demographics
NPI:1801138557
Name:BROOKDALE PLACE AT KENWOOD LLC
Entity type:Organization
Organization Name:BROOKDALE PLACE AT KENWOOD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:RIJOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-977-3700
Mailing Address - Street 1:9090 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-7712
Mailing Address - Country:US
Mailing Address - Phone:513-745-9292
Mailing Address - Fax:
Practice Address - Street 1:9090 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-7712
Practice Address - Country:US
Practice Address - Phone:513-745-9292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2143R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPPLIED FOROtherMEDICAID WAIVER