Organization
WESTERN RESERVE MASONIC COMMUNITY
Active
Parent organization
OHIO MASONIC HOME
Other names
Western Reserve Masonic Community - Laboratory
Organization subpart
Yes
Provider details
NPI number
Legal business name
OHIO MASONIC HOME
Authorized official
MR. JAY DETTORRE (PRESIDENT)
(330) 721-3000
Entity
Organization
Contact information
Practice address
4931 NETTLETON RD, MEDINA, OH 44256-5353
(330) 721-3000
Mailing address
4931 NETTLETON RD, MEDINA, OH 44256-5353
(330) 721-3000
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
36D1002841
OH
Other
Enumeration date
10/07/2009
Last updated
10/07/2009
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