NPIMap

Organization Active NPI

Grand Lake Operations, LLC

  • Skilled Nursing Facility
  • Saint Marys, OH
National Provider Identifier
1720633639
Registry record updated May 19, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
GRAND LAKE OPERATIONS, LLC
Practice address
1035 Hager Street
Saint Marys, OH 45885
Phone
(419) 394-3308
Fax
(419) 394-3300
NPI assigned
Aug 7, 2019
Last updated
May 19, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 19, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Edgar Silalahi
Title
Cfo
Phone
(419) 238-0715

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NU Primary

Addresses

Primary practice location

1035 Hager Street
Saint Marys, OH 45885

Mailing address

120 W Main St Ste 200
Van Wert, OH 45891-1761
Phone (419) 238-0715

Other identifiers 1

IdentifierTypeStateIssuer
0363613MedicaidOH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200401001070 OH Part A Provider - Skilled Nursing Facility 3577992296 Practice locations: Saint Marys, OH

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1720633639. Details of each certification follow.

Skilled nursing facility certification: CCN 365232

Legal name
GRAND LAKE OPERATIONS LLC
Doing business as
VANCREST OF ST MARY'S
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Oct 20, 1969
Last certification
Nov 22, 2023
Beds
50
Ownership / control type
Partnership
Multi-facility organization
Vancrest Healthcare Centers
Organization structure
LLCProprietary
Incorporated
Nov 21, 2017 in OH
Enrollment address
1035 Hager St
Saint Marys, OH 45885-2422
Nursing home name
VANCREST OF ST MARY'S
Affiliated entity
VANCREST HEALTH CARE CENTERS

Care Compare: Nursing home

Medicare Care Compare
Listed as
Vancrest of St Mary'sCCN 365232 · All quality measures
Overall star rating
5 of 5
Health inspections
5 of 5
Staffing
3 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
For profit - Partnership
Certified
Oct 20, 1969
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
6642.7 residents per day on average
Chain
Vancrest Health Care Centers13 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory
Tax ID family
Grand Lake Operations2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

1035 Hager St
Saint Marys, OH 45885
Phone (419) 394-3308

Ownership & related parties

All disclosed owners & managing parties 6

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jon D Bagley Individual 5% Or Greater Direct Ownership Interest Oct 16, 2019 28.5%
Corporate OfficerSecretary Oct 16, 2019
Mark Stuart McCleery Individual Corporate OfficerTreasurer Oct 16, 2019
Joint Township District Memorial Hospital Organization, Saint Marys, OH Corporation 5% Or Greater Direct Ownership Interest Oct 16, 2019 25%
Mark a White Individual 5% Or Greater Direct Ownership Interest Oct 16, 2019 33%
Corporate OfficerPresident Oct 16, 2019
Nita J. Goecke Individual W-2 Managing EmployeeAdministrator Oct 16, 2019
Operational/Managerial ControlAdministrator Oct 16, 2019
Mark L Myers Individual 5% Or Greater Direct Ownership Interest Oct 16, 2019 9%
Corporate OfficerVP Oct 16, 2019

Owners & managing parties with NPI records 7

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1565136000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1779148800000",
    "number": "1720633639",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 W MAIN ST STE 200",
            "city": "VAN WERT",
            "state": "OH",
            "postal_code": "458911761",
            "telephone_number": "419-238-0715",
            "fax_number": "419-238-4814"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1035 HAGER STREET",
            "city": "SAINT MARYS",
            "state": "OH",
            "postal_code": "45885",
            "telephone_number": "419-394-3308",
            "fax_number": "419-394-3300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAND LAKE OPERATIONS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-07",
        "last_updated": "2026-05-19",
        "certification_date": "2026-05-19",
        "status": "A",
        "authorized_official_last_name": "SILALAHI",
        "authorized_official_first_name": "EDGAR",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "419-238-0715"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0363613",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Marys, OH

Sources for this page

Verify at the official NPI Registry.