Provider Demographics
NPI:1679637987
Name:DELERISAJBLANK-INC
Entity Type:Organization
Organization Name:DELERISAJBLANK-INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELERISA
Authorized Official - Middle Name:JANET
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:HOMECARE PROVIDER
Authorized Official - Phone:937-444-3596
Mailing Address - Street 1:16507 CLEMENTS RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154-9765
Mailing Address - Country:US
Mailing Address - Phone:937-444-3596
Mailing Address - Fax:937-444-3596
Practice Address - Street 1:16507 CLEMENTS RD
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-9765
Practice Address - Country:US
Practice Address - Phone:937-444-3596
Practice Address - Fax:937-444-3596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2429312OtherHOMECARE PROVIDER