Provider Demographics
NPI:1508819798
Name:DHSC LLC
Entity Type:Organization
Organization Name:DHSC LLC
Other - Org Name:AFFINITY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3672
Mailing Address - Street 1:PO BOX 10390
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46852-0390
Mailing Address - Country:US
Mailing Address - Phone:330-837-7200
Mailing Address - Fax:330-830-1616
Practice Address - Street 1:400 AUSTIN AVE NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-3554
Practice Address - Country:US
Practice Address - Phone:330-837-7200
Practice Address - Fax:330-830-1616
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHSC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPPH04-2460273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0353853Medicaid
OH0353853Medicaid