Provider Demographics
NPI:1043463821
Name:PEREGRINE HEALTH SERVICES OF EDGERTON,LLC
Entity type:Organization
Organization Name:PEREGRINE HEALTH SERVICES OF EDGERTON,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:G
Authorized Official - Last Name:ALEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-459-2482
Mailing Address - Street 1:328 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:OH
Mailing Address - Zip Code:43517-9600
Mailing Address - Country:US
Mailing Address - Phone:419-298-2321
Mailing Address - Fax:419-298-2476
Practice Address - Street 1:328 W VINE ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:OH
Practice Address - Zip Code:43517-9600
Practice Address - Country:US
Practice Address - Phone:419-298-2321
Practice Address - Fax:419-298-2476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1410314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2902407Medicaid
OH2902407Medicaid