Provider Demographics
NPI:1275939811
Name:MOICANO HEALTHCARE PROVIDER LLC
Entity Type:Organization
Organization Name:MOICANO HEALTHCARE PROVIDER LLC
Other - Org Name:MOICANO HEALTHCARE PROVIDER LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:N
Authorized Official - Last Name:LOLA
Authorized Official - Suffix:I
Authorized Official - Credentials:DODD
Authorized Official - Phone:1800-617-6733
Mailing Address - Street 1:260 NORTHLAND BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4921
Mailing Address - Country:US
Mailing Address - Phone:513-580-3109
Mailing Address - Fax:513-818-9594
Practice Address - Street 1:260 NORTHLAND BLVD STE 320
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:OH
Practice Address - Zip Code:45246-4921
Practice Address - Country:US
Practice Address - Phone:513-580-3109
Practice Address - Fax:513-818-9594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2264980251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103628Medicaid