Provider Demographics
NPI:1114044625
Name:UNIQUE SOLUTIONS MANAGEMENT COMPANY LLC
Entity Type:Organization
Organization Name:UNIQUE SOLUTIONS MANAGEMENT COMPANY LLC
Other - Org Name:KLERMONT 4 KIDS & ADULTS 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RUDOLPH
Authorized Official - Last Name:FRY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MBA
Authorized Official - Phone:513-735-9111
Mailing Address - Street 1:6850 LOOP RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2159
Mailing Address - Country:US
Mailing Address - Phone:937-439-9366
Mailing Address - Fax:937-439-6687
Practice Address - Street 1:6850 LOOP RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2159
Practice Address - Country:US
Practice Address - Phone:937-439-9366
Practice Address - Fax:937-439-6687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30017961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2554267Medicaid
OH$$$$$$$$$OtherSSN
OH0263610Medicaid