Provider Demographics
NPI:1891186714
Name:SAMSON JAGGER CONSTRUCTION, LLC
Entity Type:Organization
Organization Name:SAMSON JAGGER CONSTRUCTION, LLC
Other - Org Name:CREATIVE BATH SYSTEMS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:CARAVONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-467-2227
Mailing Address - Street 1:51 MEADOW LN STE C
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44067-1475
Mailing Address - Country:US
Mailing Address - Phone:330-467-2227
Mailing Address - Fax:330-467-2229
Practice Address - Street 1:51 MEADOW LN STE C
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44067-1475
Practice Address - Country:US
Practice Address - Phone:330-467-2227
Practice Address - Fax:330-467-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2210563171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3100110Medicaid