1407288210 NPI number — HEALTHSOURCE OF OHIO, INC.

Table of content: (NPI 1407288210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407288210 NPI number — HEALTHSOURCE OF OHIO, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHSOURCE OF OHIO, 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:
6
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:
1407288210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
424 WARDS CORNER RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45140-6966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-707-4041
Provider Business Mailing Address Fax Number:
513-576-1020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1231 COLUMBUS AVE
Provider Second Line Business Practice Location Address:
UNIT A 1
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45036-8195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-696-4495
Provider Business Practice Location Address Fax Number:
513-228-1236
Provider Enumeration Date:
08/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PRATHER II
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
513-707-4041

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0099241 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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