Provider Demographics
NPI:1942636808
Name:HENRY COUNTY BOARD OF DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:HENRY COUNTY BOARD OF DEVELOPMENTAL DISABILITIES
Other - Org Name:HENRY COUNTY RESIDENTIAL HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SLUSSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-599-2892
Mailing Address - Street 1:135 EAST MAUMEE AVENUE
Mailing Address - Street 2:
Mailing Address - City:NAPOLEON
Mailing Address - State:OH
Mailing Address - Zip Code:43545
Mailing Address - Country:US
Mailing Address - Phone:419-599-2892
Mailing Address - Fax:419-592-5828
Practice Address - Street 1:340 E CLINTON ST
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-1606
Practice Address - Country:US
Practice Address - Phone:419-592-0238
Practice Address - Fax:419-592-0218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3510025320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36G165Medicaid