Provider Demographics
NPI:1033328422
Name:ASHTABULA COUNTY COMMUNITY ACTION AGENCY
Entity Type:Organization
Organization Name:ASHTABULA COUNTY COMMUNITY ACTION AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH & NUTRITION SERVICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-998-7515
Mailing Address - Street 1:4200 STATE RD
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6017
Mailing Address - Country:US
Mailing Address - Phone:440-998-7515
Mailing Address - Fax:440-998-0973
Practice Address - Street 1:4200 STATE RD
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6017
Practice Address - Country:US
Practice Address - Phone:440-998-7515
Practice Address - Fax:440-998-0973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0412486Medicaid