1184824344 NPI number — BE HEALED FAMILY OUTREACH

Table of content: (NPI 1184824344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184824344 NPI number — BE HEALED FAMILY OUTREACH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BE HEALED FAMILY OUTREACH
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:
SUCCESS 1 SERVICES
Provider Other Organization Name Type Code:
3
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:
1184824344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
670 BROADWAY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44146-3642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-439-9250
Provider Business Mailing Address Fax Number:
216-641-7330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
670 BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44146-3642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-439-9250
Provider Business Practice Location Address Fax Number:
216-641-7330
Provider Enumeration Date:
07/24/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RIVERS
Authorized Official First Name:
MIN. JEROME
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
216-224-4254

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  011102 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP1600X , with the licence number: E4292 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: E4292 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: F120 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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