Basic Information
| Provider Information | |||||||||
| NPI: | 1063416030 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL OHIO GROUP HOMES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MORNING VIEW CARE CENTER GROUP HOME #4 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25000 COUNTRY CLUB BLVD | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440705344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406140160 | ||||||||
| FaxNumber: | 4406140168 | ||||||||
| Practice Location | |||||||||
| Address1: | 5520 COUNTY ROAD 25 | ||||||||
| Address2: | |||||||||
| City: | CARDINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433159346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197689962 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 06/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | COLLERAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4406140160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | 5910143 | OH | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 2417549 | 05 | OH | MEDICAID |