Provider Demographics
NPI:1831389691
Name:BLC SPRINGFIELD-GC, LLC
Entity type:Organization
Organization Name:BLC SPRINGFIELD-GC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHULTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-977-3700
Mailing Address - Street 1:2981 VESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1565
Mailing Address - Country:US
Mailing Address - Phone:937-399-1216
Mailing Address - Fax:
Practice Address - Street 1:2981 VESTER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1565
Practice Address - Country:US
Practice Address - Phone:937-399-1216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1986R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPPLIED FORMedicaid