Provider Demographics
NPI:1083218390
Name:MINAMYER RESIDENTIAL MR/DD SERVICES, INC.
Entity Type:Organization
Organization Name:MINAMYER RESIDENTIAL MR/DD SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MINAMYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-802-0190
Mailing Address - Street 1:967 WORTHINGTON WOODS LOOP RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-5743
Mailing Address - Country:US
Mailing Address - Phone:614-802-0190
Mailing Address - Fax:
Practice Address - Street 1:967 WORTHINGTON WOODS LOOP RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-5743
Practice Address - Country:US
Practice Address - Phone:614-802-0190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0153559Medicaid