1790753200 NPI number — THE WAY STATION, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790753200 NPI number — THE WAY STATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WAY STATION, 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:
1790753200
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
769 SPRINGFIELD RD
Provider Second Line Business Mailing Address:
PO BOX 449
Provider Business Mailing Address City Name:
COLUMBIANA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44408-9456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-482-5072
Provider Business Mailing Address Fax Number:
330-482-5074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
432 W FIFTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST LIVERPOOL
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43920-2467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-385-7510
Provider Business Practice Location Address Fax Number:
330-385-7530
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLSOPPLE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
330-385-7510

Provider Taxonomy Codes

  • Taxonomy code: 3245S0500X , with the licence number:  11155 , 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)

  • Identifier: 11155 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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