1619901915 NPI number — COMMUNITY CARE I, INC.

Table of content: (NPI 1619901915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619901915 NPI number — COMMUNITY CARE I, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY CARE I, INC.
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:
1619901915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
715 S TAFT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREMONT
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43420-3200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-334-6624
Provider Business Mailing Address Fax Number:
419-334-6602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8153 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLD FORT
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-992-4231
Provider Business Practice Location Address Fax Number:
419-992-4722
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOOLLEY
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, MEDICAL STAFF SERVICES
Authorized Official Telephone Number:
419-334-6624

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0238951 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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