- Enrollment id
- O20180509003046
- Enrollment state
- OH
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1609394535
- Multiple npi flag
- N
- Ccn
- 365932
- Associate id
- 9436413952
- Organization name
- EDGEWOOD MANOR OF LUCASVILLE II LLC
- Doing business as name
- EDGEWOOD MANOR OF LUCASVILLE II
- Incorporation date
- 2017-07-19
- Incorporation state
- OH
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- EDGEWOOD MANOR OF LUCASVILLE II
- Affiliation entity name
- AOM HEALTHCARE
- Affiliation entity id
- 37
- Address line 1
- 10098A BIG BEAR CREEK RD
- City
- LUCASVILLE
- State
- OH
- Zip code
- 456489168