1750468237 NPI number — SPRINGFIELD HEALTH CARE OPERATING COMPANY, LLC

Table of content: MACKENZIE LEIGH SEAGROVES OTRL (NPI 1427303031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750468237 NPI number — SPRINGFIELD HEALTH CARE OPERATING COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGFIELD HEALTH CARE OPERATING COMPANY, LLC
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:
1750468237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2457 BROADWAY AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKWOOD VILLAGE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-439-7976
Provider Business Mailing Address Fax Number:
440-232-7113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 E. MCCREIGHT AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-399-8311
Provider Business Practice Location Address Fax Number:
937-399-7370
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BARTLEBAUGH
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CO-MANAGING MEMBER
Authorized Official Telephone Number:
330-425-4696

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  1044N , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 1044N , 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: 0391204 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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