Provider Demographics
NPI:1073773719
Name:CLASSIC HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:CLASSIC HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EVARISTUS
Authorized Official - Middle Name:BASIL
Authorized Official - Last Name:ITIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-848-3900
Mailing Address - Street 1:1105 SCHROCK ROAD SUITE 206
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-1704
Mailing Address - Country:US
Mailing Address - Phone:614-848-3900
Mailing Address - Fax:614-848-3901
Practice Address - Street 1:1105 SCHROCK ROAD SUITE 206
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-1704
Practice Address - Country:US
Practice Address - Phone:614-848-3900
Practice Address - Fax:614-848-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1662106251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3069816Medicaid
OH3069816Medicaid