Provider Demographics
NPI:1659555407
Name:OHIO MEDICAID PROVIDER
Entity Type:Organization
Organization Name:OHIO MEDICAID PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:SAUNDRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:937-479-1676
Mailing Address - Street 1:322 ALBERS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45427-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:322 ALBERS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45427-1703
Practice Address - Country:US
Practice Address - Phone:937-479-1676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN0830007311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2516950Medicaid