Provider Demographics
NPI:1114336625
Name:J. R. COLEMAN COMMUNITY RENOVATION CORP.
Entity Type:Organization
Organization Name:J. R. COLEMAN COMMUNITY RENOVATION CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-455-3873
Mailing Address - Street 1:1731 GRACE AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-2261
Mailing Address - Country:US
Mailing Address - Phone:330-455-3873
Mailing Address - Fax:330-455-3934
Practice Address - Street 1:1731 GRACE AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-2261
Practice Address - Country:US
Practice Address - Phone:330-455-3873
Practice Address - Fax:330-455-3934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0809227Medicaid