1184742793 NPI number — SHELBY COUNTY BOARD OF MRDD

Table of content: (NPI 1184742793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184742793 NPI number — SHELBY COUNTY BOARD OF MRDD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELBY COUNTY BOARD OF MRDD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184742793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 CHILDRENS HOME RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIDNEY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45365-7731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-497-8155
Provider Business Mailing Address Fax Number:
937-498-4567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 CHILDRENS HOME RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIDNEY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45365-7731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-497-8155
Provider Business Practice Location Address Fax Number:
937-498-4567
Provider Enumeration Date:
03/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ZUREICH
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERINTENDENT
Authorized Official Telephone Number:
937-497-8155

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  7500010 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 251C00000X , with the licence number: 7500010 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2556069 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7500010 . This is a "ODMRDD CONTRACT NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".