Provider Demographics
NPI:1881290047
Name:WEST LIBERTY CARE CENTER INC
Entity type:Organization
Organization Name:WEST LIBERTY CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-650-7103
Mailing Address - Street 1:6557 US HIGHWAY 68 S
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-9536
Mailing Address - Country:US
Mailing Address - Phone:937-465-3895
Mailing Address - Fax:
Practice Address - Street 1:6557 US HIGHWAY 68 S
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:OH
Practice Address - Zip Code:43357-9536
Practice Address - Country:US
Practice Address - Phone:937-465-3895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST LIBERTY CARE CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-11
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2965822Medicaid