Provider Demographics
NPI:1164481487
Name:HUCKLEBERRY HOUSE, INC.
Entity Type:Organization
Organization Name:HUCKLEBERRY HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LECLERC
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:614-294-8097
Mailing Address - Street 1:1421 HAMLET ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2533
Mailing Address - Country:US
Mailing Address - Phone:614-294-8097
Mailing Address - Fax:614-294-6109
Practice Address - Street 1:1421 HAMLET ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2533
Practice Address - Country:US
Practice Address - Phone:614-294-8097
Practice Address - Fax:614-294-6109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03164Medicaid