Provider Demographics
NPI:1912988718
Name:SPRING MEADOW EXTENDED CARE CENTER FACILITY INC
Entity Type:Organization
Organization Name:SPRING MEADOW EXTENDED CARE CENTER FACILITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:E
Authorized Official - Last Name:WITKER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:419-866-6124
Mailing Address - Street 1:1125 CLARION AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-8107
Mailing Address - Country:US
Mailing Address - Phone:419-866-6124
Mailing Address - Fax:419-861-6996
Practice Address - Street 1:1125 CLARION AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-8107
Practice Address - Country:US
Practice Address - Phone:419-866-6124
Practice Address - Fax:419-861-6996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1823R310400000X
OH1823314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0580572Medicaid
OH366042Medicare Oscar/Certification