Provider Demographics
NPI:1205887130
Name:AMANDACARE, INC.
Entity type:Organization
Organization Name:AMANDACARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-884-8880
Mailing Address - Street 1:6430 E MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2367
Mailing Address - Country:US
Mailing Address - Phone:614-884-8880
Mailing Address - Fax:614-884-8886
Practice Address - Street 1:6430 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2367
Practice Address - Country:US
Practice Address - Phone:614-884-8880
Practice Address - Fax:614-884-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2011594251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2011594Medicaid
OH367736Medicare Oscar/Certification