Provider Demographics
NPI:1255010070
Name:BEACON SPECIALIZED LIVING OHIO INC
Entity type:Organization
Organization Name:BEACON SPECIALIZED LIVING OHIO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPS/BIZ DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:PELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-330-3073
Mailing Address - Street 1:967 WORTHINGTON WOODS LOOP RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-5743
Mailing Address - Country:US
Mailing Address - Phone:614-330-3073
Mailing Address - Fax:
Practice Address - Street 1:1293 REDBUD DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5834
Practice Address - Country:US
Practice Address - Phone:937-874-5001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEYSTONE COMMUNITY RESOURCES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities