Provider Demographics
NPI:1639164205
Name:PORTAGE COUNTY BOARD OF DEVELOPMENTAL DISABILIT
Entity Type:Organization
Organization Name:PORTAGE COUNTY BOARD OF DEVELOPMENTAL DISABILIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-297-6209
Mailing Address - Street 1:2606 BRADY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1604
Mailing Address - Country:US
Mailing Address - Phone:330-297-6209
Mailing Address - Fax:330-297-1202
Practice Address - Street 1:7008 STATE ROUTE 88
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-9188
Practice Address - Country:US
Practice Address - Phone:330-296-2839
Practice Address - Fax:330-297-8875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTAGE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-20
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0776129251B00000X
OH2560072251C00000X, 251E00000X, 251K00000X, 251S00000X, 344600000X, 347B00000X, 347C00000X
OH252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No344600000XTransportation ServicesTaxi
No347B00000XTransportation ServicesBus
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6700010Medicaid