Provider Demographics
NPI:1366558157
Name:HARBORSIDE OF DAYTON LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:HARBORSIDE OF DAYTON LIMITED PARTNERSHIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIVITTORIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-821-3355
Mailing Address - Street 1:101 SUN AVE NE
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4373
Mailing Address - Country:US
Mailing Address - Phone:505-468-5604
Mailing Address - Fax:505-468-4681
Practice Address - Street 1:323 FOREST AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4599
Practice Address - Country:US
Practice Address - Phone:937-224-0793
Practice Address - Fax:937-224-0799
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-22
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5318314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2083776Medicaid
365981Medicare Oscar/Certification