Provider Demographics
NPI:1932198710
Name:SOUTHBROOK HEALTH CARE CENTER, INC.
Entity Type:Organization
Organization Name:SOUTHBROOK HEALTH CARE CENTER, INC.
Other - Org Name:SOUTHBROOK CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:SOSNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-561-4105
Mailing Address - Street 1:2299 SOUTH YELLOW SPRINGS STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45506
Mailing Address - Country:US
Mailing Address - Phone:937-322-3436
Mailing Address - Fax:937-322-2470
Practice Address - Street 1:2299 S YELLOW SPRINGS ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45506-3221
Practice Address - Country:US
Practice Address - Phone:937-322-3436
Practice Address - Fax:937-322-2470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6219314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2319566Medicaid
OH2319566Medicaid