Provider Demographics
NPI:1558143164
Name:INTERVAL BROTHERHOOD HOMES, INC.
Entity Type:Organization
Organization Name:INTERVAL BROTHERHOOD HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-237-6943
Mailing Address - Street 1:3445 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COVENTRY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44319-3028
Mailing Address - Country:US
Mailing Address - Phone:330-644-4095
Mailing Address - Fax:
Practice Address - Street 1:1601 S MAIN ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44301-1664
Practice Address - Country:US
Practice Address - Phone:330-644-4095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health