Provider Demographics
NPI:1023370533
Name:AMETHYST, INC.
Entity Type:Organization
Organization Name:AMETHYST, INC.
Other - Org Name:AMETHYST, INC. MEDICAID MH
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:614-242-1284
Mailing Address - Street 1:455 E MOUND ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5595
Mailing Address - Country:US
Mailing Address - Phone:614-242-1284
Mailing Address - Fax:614-242-1286
Practice Address - Street 1:455 E MOUND ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5595
Practice Address - Country:US
Practice Address - Phone:614-242-1284
Practice Address - Fax:614-242-1286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846620Medicaid