Basic Information
| Provider Information | |||||||||
| NPI: | 1023605417 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAISE GEAUGA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 N WHITTINGTON PKWY | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402227101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023942100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5099 CAMELOT DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450147423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138584550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2020 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHOBREY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5026307249 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 343900000X | N | Transportation Services | Non-emergency Medical Transport (VAN) | 3747P1801X | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Technician | Personal Care Attendant |
No ID Information.