Provider Demographics
NPI:1619901915
Name:COMMUNITY CARE I, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE I, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, MEDICAL STAFF SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPMSM, CPCS
Authorized Official - Phone:419-334-6624
Mailing Address - Street 1:715 S TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3200
Mailing Address - Country:US
Mailing Address - Phone:419-334-6624
Mailing Address - Fax:419-334-6602
Practice Address - Street 1:8153 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OLD FORT
Practice Address - State:OH
Practice Address - Zip Code:44861
Practice Address - Country:US
Practice Address - Phone:419-992-4231
Practice Address - Fax:419-992-4722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0238951Medicaid
OHDF9133Medicare PIN
OHCO9284782Medicare PIN
OHCK2511Medicare PIN
OHCO9284783Medicare PIN