1801919584 NPI number — OTTERBEIN MONCLOVA, LLC

Table of content: (NPI 1801919584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801919584 NPI number — OTTERBEIN MONCLOVA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OTTERBEIN MONCLOVA, 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:
1801919584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
580 N STATE ROUTE 741
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45036-8839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-933-5401
Provider Business Mailing Address Fax Number:
513-932-1054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5069 OTTERBEIN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONCLOVA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-878-0550
Provider Business Practice Location Address Fax Number:
419-878-3169
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
CHRIS
Authorized Official Title or Position:
TREASURER & CFO
Authorized Official Telephone Number:
513-933-5418

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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: 2503N , 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: 2819454 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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