Provider Demographics
NPI:1417108382
Name:WEEBLES
Entity Type:Organization
Organization Name:WEEBLES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-934-6152
Mailing Address - Street 1:38135 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-1028
Mailing Address - Country:US
Mailing Address - Phone:440-934-6152
Mailing Address - Fax:440-934-0430
Practice Address - Street 1:48199 US ROUTE 20
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074
Practice Address - Country:US
Practice Address - Phone:440-775-4303
Practice Address - Fax:440-775-4143
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE WAYSIDE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4710834320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2362670Medicaid