Provider Demographics
NPI:1083828305
Name:MASSILLON HEALTH DEPT
Entity Type:Organization
Organization Name:MASSILLON HEALTH DEPT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:JENAY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-830-1713
Mailing Address - Street 1:111 TREMONT AVE SW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44647-6571
Mailing Address - Country:US
Mailing Address - Phone:330-830-1713
Mailing Address - Fax:330-830-2852
Practice Address - Street 1:111 TREMONT AVE SW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-6571
Practice Address - Country:US
Practice Address - Phone:330-830-1713
Practice Address - Fax:330-830-2852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X
OHRN260840251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0873407Medicaid
OH0873407Medicaid