Provider Demographics
NPI:1952483455
Name:THE LAURELS OF ROCKFORD, INC.
Entity Type:Organization
Organization Name:THE LAURELS OF ROCKFORD, INC.
Other - Org Name:THE LAURELS OF SHANE HILL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-794-8800
Mailing Address - Street 1:10731 STATE ROUTE 118
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45882-8947
Mailing Address - Country:US
Mailing Address - Phone:419-363-2620
Mailing Address - Fax:419-363-2354
Practice Address - Street 1:10731 STATE ROUTE 118
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:OH
Practice Address - Zip Code:45882-8947
Practice Address - Country:US
Practice Address - Phone:419-363-2620
Practice Address - Fax:419-363-2354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5801332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7105594OtherUNITED HEALTH CARE ID #
OH5801OtherNH LICENSE #
OH2165286Medicaid
OH000000253127OtherBC/BS #
OH000000253127OtherBC/BS #