Provider Demographics
NPI:1215029525
Name:WOOD LANE RESIDENTIAL SERVICES, INC.
Entity Type:Organization
Organization Name:WOOD LANE RESIDENTIAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-353-9577
Mailing Address - Street 1:545 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2731
Mailing Address - Country:US
Mailing Address - Phone:419-353-9577
Mailing Address - Fax:
Practice Address - Street 1:349 W MAIN ST.
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:OH
Practice Address - Zip Code:43451
Practice Address - Country:US
Practice Address - Phone:419-353-9577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH320600000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36G261Medicaid
OH36G260Medicaid
OH36G381Medicaid
OH2585751Medicaid
OH36G344Medicaid
OH36G475Medicaid
OH36G087Medicaid
OH36G345Medicaid
OH36G474Medicaid