Western Reserve Masonic Community

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

36D1002841 Issued in OH

Legal business name

WESTERN RESERVE MASONIC COMMUNITY

Practice address

4931 Nettleton Rd
Medina, OH 44256-5353

Phone

(330) 721-3000

NPI assigned

Oct 7, 2009

Organization subpart

Yes

Parent organization

OHIO MASONIC HOMEAs reported in NPPES

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

Authorized official

Name

Mr. Jay Dettorre

Title

President

Phone

(330) 721-3000

Specialties & licenses 1

Addresses

Other names 1

• Western Reserve Masonic Community - Laboratory Doing business as

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

The Ohio Masonic Home2 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.

• The Ohio Masonic Home

  • Skilled Nursing Facility
  • Medina, OH
  • NPI 1144241324
  NPD tax ID

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

{
    "created_epoch": "1254873600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1254873600000",
    "number": "1740515865",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4931 NETTLETON RD",
            "city": "MEDINA",
            "state": "OH",
            "postal_code": "442565353",
            "telephone_number": "330-721-3000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4931 NETTLETON RD",
            "city": "MEDINA",
            "state": "OH",
            "postal_code": "442565353",
            "telephone_number": "330-721-3000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WESTERN RESERVE MASONIC COMMUNITY",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "OHIO MASONIC HOME",
        "enumeration_date": "2009-10-07",
        "last_updated": "2009-10-07",
        "status": "A",
        "authorized_official_last_name": "DETTORRE",
        "authorized_official_first_name": "JAY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "330-721-3000",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "OH",
            "license": "36D1002841",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Western Reserve Masonic Community - Laboratory",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Cristina Noelle Wells, PTA, AT
• Skye W. Wells, PA-C
• Wellstreet of Georgia PC
• Carol Ann Wendt
• Susan K Wentz, PRS BA
• Kyla Westrick, CNP
• Isabella Perez Wheeler
• Dennis White, LICDC-CS
• Jeffrey J. White, DDS, MSD
• Merae L Whitmyer, O.T.A.

• Clinical Medical Laboratory in Medina, OH
• Providers in Medina, OH by specialty
• Clinical Medical Laboratory in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 7, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.