Basic Information
Provider Information | |||||||||
NPI: | 1922287762 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORION MANSFIELD, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WOODSIDE VILLAGE CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 EASTON OVAL | ||||||||
Address2: | SUITE 300 | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432196061 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6144160600 | ||||||||
FaxNumber: | 6144160204 | ||||||||
Practice Location | |||||||||
Address1: | 841 W MARION RD | ||||||||
Address2: |   | ||||||||
City: | MOUNT GILEAD | ||||||||
State: | OH | ||||||||
PostalCode: | 433381031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4199472015 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2007 | ||||||||
LastUpdateDate: | 10/29/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YODER | ||||||||
AuthorizedOfficialFirstName: | KEITH | ||||||||
AuthorizedOfficialMiddleName: | JAMES | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6144160600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
ID | Type | State | Issuer | Description | 2740172 | 05 | OH |   | MEDICAID |