1053565986 NPI number — FAMILY STATCARE OF NORTHEAST OHIO, LLC

Table of content: (NPI 1053565986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053565986 NPI number — FAMILY STATCARE OF NORTHEAST OHIO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
FAMILY STATCARE OF NORTHEAST OHIO, LLC
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:
1053565986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 QUADRAL DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
WADSWORTH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44281-8376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-336-3280
Provider Business Mailing Address Fax Number:
330-336-5325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 GREAT OAKS TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WADSWORTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44281-8712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-336-3588
Provider Business Practice Location Address Fax Number:
330-336-1328
Provider Enumeration Date:
11/05/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FILBERT
Authorized Official First Name:
KEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
330-416-6153

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2939511 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".