Provider Demographics
NPI:1801919584
Name:OTTERBEIN MONCLOVA, LLC
Entity type:Organization
Organization Name:OTTERBEIN MONCLOVA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER & CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:513-933-5418
Mailing Address - Street 1:580 N STATE ROUTE 741
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8839
Mailing Address - Country:US
Mailing Address - Phone:513-933-5401
Mailing Address - Fax:513-932-1054
Practice Address - Street 1:5069 OTTERBEIN WAY
Practice Address - Street 2:
Practice Address - City:MONCLOVA
Practice Address - State:OH
Practice Address - Zip Code:43542
Practice Address - Country:US
Practice Address - Phone:419-878-0550
Practice Address - Fax:419-878-3169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH314000000X
OH2503N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2819454Medicaid
OH366361Medicare Oscar/Certification