Provider Demographics
NPI:1851849442
Name:DEFIANCE COUNTY BOARD OF DD
Entity Type:Organization
Organization Name:DEFIANCE COUNTY BOARD OF DD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-782-6621
Mailing Address - Street 1:195 ISLAND PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2561
Mailing Address - Country:US
Mailing Address - Phone:419-782-6621
Mailing Address - Fax:
Practice Address - Street 1:195 ISLAND PARK AVE
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2561
Practice Address - Country:US
Practice Address - Phone:419-782-6621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-13
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2556416Medicaid
OH2568458Medicaid
OH0790694Medicaid