1982605507 NPI number — CANTON CHRISTIAN HOME, INC

Table of content: (NPI 1982605507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982605507 NPI number — CANTON CHRISTIAN HOME, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANTON CHRISTIAN HOME, 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:
1982605507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 CLEVELAND AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44709-3306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-456-0004
Provider Business Mailing Address Fax Number:
330-452-9951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 CLEVELAND AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44709-3306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-456-0004
Provider Business Practice Location Address Fax Number:
330-452-9951
Provider Enumeration Date:
08/04/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STROBL
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
330-456-0004

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1618N , 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: 0345237 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1618N . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1618R . This is a "RESCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".