Provider Demographics
NPI:1942397591
Name:CHILD HEALTH SERVICES OF PORTAGE COUNTY
Entity Type:Organization
Organization Name:CHILD HEALTH SERVICES OF PORTAGE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-297-5437
Mailing Address - Street 1:449 S MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-2914
Mailing Address - Country:US
Mailing Address - Phone:330-297-5437
Mailing Address - Fax:330-297-4556
Practice Address - Street 1:449 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-2914
Practice Address - Country:US
Practice Address - Phone:330-297-5437
Practice Address - Fax:330-297-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0453049261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0453049Medicaid