Basic Information
| Provider Information | |||||||||
| NPI: | 1699114108 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOWER LIGHTS CHRISTIAN HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UNION STAR HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432221317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142741455 | ||||||||
| FaxNumber: | 6142741433 | ||||||||
| Practice Location | |||||||||
| Address1: | 773 S WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430401643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142741455 | ||||||||
| FaxNumber: | 6142741433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OSBORNE | ||||||||
| AuthorizedOfficialFirstName: | CLIFFORD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6142741544 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 0455637 | 05 | OH | MEDICAID |