Provider Demographics
NPI:1639710361
Name:SOARING ON SUCCESS, LLC
Entity Type:Organization
Organization Name:SOARING ON SUCCESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MSW
Authorized Official - Phone:419-705-8682
Mailing Address - Street 1:2146 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1909
Mailing Address - Country:US
Mailing Address - Phone:419-705-8682
Mailing Address - Fax:
Practice Address - Street 1:2146 N 13TH ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43620-1909
Practice Address - Country:US
Practice Address - Phone:419-705-8682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health