Provider Demographics
NPI:1689290082
Name:CRIDERSVILLE NURSING HOME OPERATING COMPANY, LLC
Entity type:Organization
Organization Name:CRIDERSVILLE NURSING HOME OPERATING COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGYANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:330-620-7828
Mailing Address - Street 1:5915 LANDERBROOK DR STE 350
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-4063
Mailing Address - Country:US
Mailing Address - Phone:330-620-7828
Mailing Address - Fax:216-428-2055
Practice Address - Street 1:603 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CRIDERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45806-2411
Practice Address - Country:US
Practice Address - Phone:419-645-4468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-22
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1580NOtherLICENSURE