Provider Demographics
NPI:1841267259
Name:MENNONITE MEMORIAL HOME
Entity type:Organization
Organization Name:MENNONITE MEMORIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:B
Authorized Official - Last Name:VOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-358-1015
Mailing Address - Street 1:410 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817-1122
Mailing Address - Country:US
Mailing Address - Phone:419-358-1015
Mailing Address - Fax:419-358-1919
Practice Address - Street 1:410 W ELM ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817-1122
Practice Address - Country:US
Practice Address - Phone:419-358-1015
Practice Address - Fax:419-358-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6145314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0228640Medicaid
OH0228640Medicaid