Basic Information
| Provider Information | |||||||||
| NPI: | 1972788768 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUR COUNTY FAMILY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7320 STATE HIGHWAY 108 | ||||||||
| Address2: | |||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435678200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193353462 | ||||||||
| FaxNumber: | 4193353462 | ||||||||
| Practice Location | |||||||||
| Address1: | 7320 STATE HIGHWAY 108 | ||||||||
| Address2: | |||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435678200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193353462 | ||||||||
| FaxNumber: | 4193353462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2007 | ||||||||
| LastUpdateDate: | 12/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | HEFFLINGER | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE | ||||||||
| AuthorizedOfficialTelephone: | 4193353732 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY SERVICES OF NWO | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | PN088950 | OH | Y | Agencies | Nursing Care |
ID Information
| ID | Type | State | Issuer | Description | PN088950 | 01 | OH | LPN LICENSURE | OTHER |