Basic Information
Provider Information | |||||||||
NPI: | 1265434468 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL OHIO GROUP HOMES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MORNING VIEW CARE CENTER GROUP HOME #1 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 5944 MARION MOUNT GILEAD RD | ||||||||
Address2: |   | ||||||||
City: | CALEDONIA | ||||||||
State: | OH | ||||||||
PostalCode: | 433149417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403899711 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2005 | ||||||||
LastUpdateDate: | 06/16/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COLLERAN | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4406140160 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | 5110383 | OH | Y |   | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |   |
ID Information
ID | Type | State | Issuer | Description | 2417558 | 05 | OH |   | MEDICAID |