Basic Information
| Provider Information | |||||||||
| NPI: | 1194179150 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACCESS OHIO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ACCESS OHIO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 E BROAD ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432132979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146553345 | ||||||||
| FaxNumber: | 6143174689 | ||||||||
| Practice Location | |||||||||
| Address1: | 2611 WAYNE AVE BLDG 64 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454201833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142567811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2016 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9372280579 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 13909 | OH | N | Agencies | Community/Behavioral Health | 324500000X | 13908 | OH | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 2892919 | 05 | OH | MEDICAID | 0166703 | 05 | OH | MEDICAID |