Provider Demographics
NPI:1528596467
Name:WOOD LANE RESIDENTIAL SERVICES, INC.
Entity Type:Organization
Organization Name:WOOD LANE RESIDENTIAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
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 1:1005 KLOTZ RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4820
Practice Address - Country:US
Practice Address - Phone:419-353-9577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH32700315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities