Provider Demographics
NPI:1316568603
Name:WOOD LANE RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:WOOD LANE RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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:43402-2784
Mailing Address - Country:US
Mailing Address - Phone:419-353-9577
Mailing Address - Fax:
Practice Address - Street 1:351 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:OH
Practice Address - Zip Code:43451-9802
Practice Address - Country:US
Practice Address - Phone:419-686-6951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities