Provider Demographics
NPI:1326539917
Name:TEHG, LLC
Entity Type:Organization
Organization Name:TEHG, LLC
Other - Org Name:THE ELLIS HOUSE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:BONIEN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-277-9843
Mailing Address - Street 1:40 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-1407
Mailing Address - Country:US
Mailing Address - Phone:419-277-9843
Mailing Address - Fax:419-710-8558
Practice Address - Street 1:40 S 2ND ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-1407
Practice Address - Country:US
Practice Address - Phone:419-277-9843
Practice Address - Fax:419-710-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-20
Last Update Date:2018-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHH483460207Q00000X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0180404Medicaid