NPIMap

Organization Active NPI

Otterbein Monclova, LLC

Doing business as Avalon by Otterbein Monclova

  • Skilled Nursing Facility
  • Monclova, OH
National Provider Identifier
1801919584
Registry record updated Feb 9, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
2503N Issued in OH
Legal business name
OTTERBEIN MONCLOVA, LLC
Doing business as
Avalon by Otterbein Monclova
Practice address
5069 Otterbein Way
Monclova, OH 43542
Phone
(419) 878-0550
Fax
(419) 878-3169
NPI assigned
Apr 9, 2007
Last updated
Feb 9, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 9, 2015

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

Authorized official

Name
James Chris Green, CPA
Title
Treasurer & Cfo
Phone
(513) 933-5418

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X OH
Skilled Nursing Facility 314000000X 2503N OH Primary

Addresses

Primary practice location

5069 Otterbein Way
Monclova, OH 43542

Mailing address

580 N State Route 741
Lebanon, OH 45036-8839
Phone (513) 933-5401

Other identifiers 1

IdentifierTypeStateIssuer
2819454MedicaidOH

Other names 1

  • Avalon by Otterbein Monclova Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080408000228 OH Part A Provider - Skilled Nursing Facility 9335226877 Practice locations: Monclova, OH

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1801919584. Details of each certification follow.

Skilled nursing facility certification: CCN 366361

Legal name
OTTERBEIN MONCLOVA LLC
Doing business as
AVALON BY OTTERBEIN MONCLOVA
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
May 20, 2008
Last certification
Mar 27, 2025
Beds
60
Ownership / control type
Federal
Multi-facility organization
Otterbein SeniorLife
Organization structure
LLCNon-profit
Incorporated
Aug 29, 2006 in OH
Enrollment address
5069 Otterbein Way
Monclova, OH 43542-8500
Nursing home name
OTTERBEIN MONCLOVA
Affiliated entity
OTTERBEIN SENIORLIFE

Care Compare: Nursing home

Medicare Care Compare
Listed as
Otterbein MonclovaCCN 366361 · All quality measures
Overall star rating
2 of 5
Health inspections
2 of 5
Staffing
3 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
Government - Federal
Certified
May 20, 2008
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
6055.8 residents per day on average
Chain
Otterbein Seniorlife20 facilities in the chain
Penalties (3 years)
1Fines totaling $47,171

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
36D1083200Avalon by Otterbein Monclova5069 Otterbein Way, Monclova, OH 43542Certificate of waiverApr 28, 2028

National Provider Directory

National Provider Directory

Locations

5060 Otterbein Way
Monclova, OH 43542
Phone (419) 878-0550

5076 Otterbein Way
Monclova, OH 43542
Phone (419) 878-0550

5085 Otterbein Way
Monclova, OH 43542
Phone (419) 878-0550

5090 Otterbein Way
Monclova, OH 43542
Phone (419) 878-0550

Ownership & related parties

All disclosed owners & managing parties 18

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

NameRoleSinceShare
Becky Bayliff Individual Operational/Managerial Control Dec 1, 2021
Polaris Pharmacy Services of Ohio LLC Organization, Columbus, OH LLC, Medical provider/supplier, Consulting firm, For-profit Adp of the SNF Dec 1, 2018
Heidi Glosser Individual Operational/Managerial Control Dec 1, 2021
Victoria Bartlett Individual Operational/Managerial Control Dec 1, 2021
William Brownson Individual Operational/Managerial Control Dec 1, 2021
Tomas Hazelbaker Individual Operational/Managerial Control Dec 1, 2021
Ralph Reed Fraley Individual Operational/Managerial Control Dec 1, 2021
Functional Pathways of Tennessee LLC Organization, Knoxville, TN LLC, Medical provider/supplier, Medical staffing company, For-profit Operational/Managerial Control Dec 1, 2018
Adp of the SNF Apr 3, 2025
Otterbein Neighborhoods, LLC Organization, Lebanon, OH LLC, Non-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 1, 2016 100%
Jill Wilson Individual Corporate OfficerPresident/Ceo May 1, 2009
Otterbein Home Organization, Lebanon, OH Corporation, Non-profit, Chain home office 5% Or Greater Indirect Ownership Interest Dec 1, 2021 100%
Operational/Managerial Control Dec 1, 2021
Adp of the SNF Dec 1, 2021
Ashley Brough Individual Operational/Managerial Control Sep 12, 2022
Adp of the SNF Sep 12, 2022
James Christopher Green Individual Corporate OfficerVP/Treasurer/Cfo Nov 21, 2005
Operational/Managerial Control Dec 1, 2021
Robert Coleman Individual Operational/Managerial Control Dec 1, 2021
Daniel Burke Individual Operational/Managerial Control Dec 1, 2021
Lynn App Individual Operational/Managerial Control Dec 1, 2021
Cletus Uzogo Iwuagwu Individual Adp of the SNF Dec 1, 2021
Steve Vonderhaar Individual Operational/Managerial Control Dec 1, 2021

Owners & managing parties with NPI records 1

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

Facilities with the same owner 27

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

View all 27

Practitioners & affiliated clinicians

Practitioners 4

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 2

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": "1176076800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1423440000000",
    "number": "1801919584",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "580 N STATE ROUTE 741",
            "city": "LEBANON",
            "state": "OH",
            "postal_code": "450368839",
            "telephone_number": "513-933-5401",
            "fax_number": "513-932-1054"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5069 OTTERBEIN WAY",
            "city": "MONCLOVA",
            "state": "OH",
            "postal_code": "43542",
            "telephone_number": "419-878-0550",
            "fax_number": "419-878-3169"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OTTERBEIN MONCLOVA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-09",
        "last_updated": "2015-02-09",
        "status": "A",
        "authorized_official_last_name": "GREEN",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "CHRIS",
        "authorized_official_title_or_position": "TREASURER & CFO",
        "authorized_official_telephone_number": "513-933-5418",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "OH",
            "license": "2503N",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2819454",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Avalon by Otterbein Monclova",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Monclova, OH

Sources for this page

Verify at the official NPI Registry.