Provider Demographics
NPI:1255515334
Name:WAIVER PROVIDER
Entity type:Organization
Organization Name:WAIVER PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:HOPE
Authorized Official - Last Name:STANDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-606-5213
Mailing Address - Street 1:1645 HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-3555
Mailing Address - Country:US
Mailing Address - Phone:419-606-5213
Mailing Address - Fax:
Practice Address - Street 1:1645 HARDING AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-3555
Practice Address - Country:US
Practice Address - Phone:419-606-5213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.124691-IV251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPN.124691-IVOtherLPN LICENSE