Provider Demographics
NPI:1003242934
Name:EASTON PROVIDER SERVICES
Entity Type:Organization
Organization Name:EASTON PROVIDER SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:N
Authorized Official - Last Name:TALIEH
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:614-352-7092
Mailing Address - Street 1:6100 CHANNINGWAY BLVD STE 508
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-2910
Mailing Address - Country:US
Mailing Address - Phone:614-352-7092
Mailing Address - Fax:614-890-1161
Practice Address - Street 1:6100 CHANNINGWAY BLVD STE 508
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-2910
Practice Address - Country:US
Practice Address - Phone:614-352-7092
Practice Address - Fax:614-890-1161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2526609385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2526609OtherDODD CONTRACT NUMBER
OH2570141OtherODJFS MEDICAID PROVIDER NUMBER