Provider Demographics
NPI:1336503309
Name:STONE LAKE DAYCARE CENTER LLC
Entity Type:Organization
Organization Name:STONE LAKE DAYCARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:614-348-3888
Mailing Address - Street 1:144 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43074-9223
Mailing Address - Country:US
Mailing Address - Phone:614-348-3888
Mailing Address - Fax:
Practice Address - Street 1:144 N COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:OH
Practice Address - Zip Code:43074-9223
Practice Address - Country:US
Practice Address - Phone:614-348-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3008060Medicaid