1740313113 NPI number — PUTNAM COUNTY BOARD OF MENTAL RETARDATION

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 1740313113 NPI number — PUTNAM COUNTY BOARD OF MENTAL RETARDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUTNAM COUNTY BOARD OF MENTAL RETARDATION
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:
1740313113
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7989 STATE ROUTE 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTTAWA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45875-9678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7989 STATE ROUTE 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45875-9678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-876-3944
Provider Business Practice Location Address Fax Number:
419-876-3945
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEOPOLD
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERINTENDENT
Authorized Official Telephone Number:
419-876-3944

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  0840022 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 251C00000X , with the licence number: 0840022 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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