Basic Information
| Provider Information | |||||||||
| NPI: | 1114092814 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARNATION CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 S ARCH AVE | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446014202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308210201 | ||||||||
| FaxNumber: | 3308211924 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S ARCH AVE | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446014202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308210201 | ||||||||
| FaxNumber: | 3308211924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 06/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | BAUTISTA | ||||||||
| AuthorizedOfficialFirstName: | RASARIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR MGR | ||||||||
| AuthorizedOfficialTelephone: | 3308210201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | CK0913 | 01 | OH | RAILROAD MEDICARE | OTHER | 0103640 | 05 | OH | MEDICAID | 127480600 | 01 | OH | FEDERAL EMPLOYEE BWC | OTHER |