Provider Demographics
NPI:1114324415
Name:NORTHWEST TLD SERVICES LLC
Entity Type:Organization
Organization Name:NORTHWEST TLD SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAMRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-450-6092
Mailing Address - Street 1:2662 WOODVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:43619-1446
Mailing Address - Country:US
Mailing Address - Phone:419-450-6092
Mailing Address - Fax:
Practice Address - Street 1:2662 WOODVILLE RD
Practice Address - Street 2:
Practice Address - City:NORTHWOOD
Practice Address - State:OH
Practice Address - Zip Code:43619-1446
Practice Address - Country:US
Practice Address - Phone:419-450-6092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4807730Medicaid