Provider Demographics
NPI:1740558188
Name:SCIOTO GROUP HOME, INC.
Entity Type:Organization
Organization Name:SCIOTO GROUP HOME, INC.
Other - Org Name:SCIOTO TRAILS MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLERAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-614-0160
Mailing Address - Street 1:25000 COUNTRY CLUB BLVD
Mailing Address - Street 2:STE 255
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-5344
Mailing Address - Country:US
Mailing Address - Phone:440-614-0160
Mailing Address - Fax:440-614-0168
Practice Address - Street 1:374 GOOD MANOR RD
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-9606
Practice Address - Country:US
Practice Address - Phone:740-289-2861
Practice Address - Fax:440-289-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6610055OtherDODD FACILITY NUMBER