Provider Demographics
NPI:1073115978
Name:OUTLAND INTERNATIONAL LTD
Entity Type:Organization
Organization Name:OUTLAND INTERNATIONAL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:BASHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-873-3566
Mailing Address - Street 1:6371 NEWGRANGE DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-8618
Mailing Address - Country:US
Mailing Address - Phone:614-873-3566
Mailing Address - Fax:
Practice Address - Street 1:6371 NEWGRANGE DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-8618
Practice Address - Country:US
Practice Address - Phone:614-873-3566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-15
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0104760Medicaid