Basic Information
| Provider Information | |||||||||
| NPI: | 1174781207 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONSOLIDATED CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 817 | ||||||||
| Address2: | 1521 N DETROIT ST | ||||||||
| City: | WEST LIBERTY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433570817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374658065 | ||||||||
| FaxNumber: | 9374650442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 N DETROIT ST | ||||||||
| Address2: | |||||||||
| City: | WEST LIBERTY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433570817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374658065 | ||||||||
| FaxNumber: | 9374650442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2008 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | REMINDER | ||||||||
| AuthorizedOfficialFirstName: | RANDELL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9374658065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LPCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2485743 | 05 | OH | MEDICAID |