Provider Demographics
NPI:1619092616
Name:OTTAWA COUNTY BOARD OF MRDD
Entity Type:Organization
Organization Name:OTTAWA COUNTY BOARD OF MRDD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-898-0400
Mailing Address - Street 1:235 N TOUSSAINT SOUTH
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:43449
Mailing Address - Country:US
Mailing Address - Phone:419-898-0400
Mailing Address - Fax:
Practice Address - Street 1:235 N TOUSSAINT SOUTH
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449
Practice Address - Country:US
Practice Address - Phone:419-898-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0773097Medicaid