Provider Demographics
NPI:1073913539
Name:SAMIRA ADULT FOSTER HOME, LLC
Entity Type:Organization
Organization Name:SAMIRA ADULT FOSTER HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HALIMATOU
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-596-3340
Mailing Address - Street 1:4258 COLBY AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-2028
Mailing Address - Country:US
Mailing Address - Phone:614-596-3340
Mailing Address - Fax:
Practice Address - Street 1:4258 COLBY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2028
Practice Address - Country:US
Practice Address - Phone:614-596-3340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105170Medicaid