Provider Demographics
NPI:1750686770
Name:419-647-4584.
Entity Type:Organization
Organization Name:419-647-4584.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STUDENT
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-647-9999
Mailing Address - Street 1:102 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SPENCERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45887-1267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPENCERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45887-1267
Practice Address - Country:US
Practice Address - Phone:614-582-9253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-23
Last Update Date:2011-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH788776765655305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH574184689203Medicaid