Provider Demographics
NPI:1174670285
Name:DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:D
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-272-0509
Mailing Address - Street 1:30 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3414
Mailing Address - Country:US
Mailing Address - Phone:614-466-1970
Mailing Address - Fax:
Practice Address - Street 1:1601 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1054
Practice Address - Country:US
Practice Address - Phone:614-272-0509
Practice Address - Fax:614-272-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2514097310500000X, 315P00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2438080Medicaid
OH9333787Medicare PIN