Provider Demographics
NPI:1477962975
Name:J. R. COLEMAN SENIOR OUTREACH SERVICES, INC.
Entity type:Organization
Organization Name:J. R. COLEMAN SENIOR OUTREACH SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-455-3873
Mailing Address - Street 1:1731 GRACE AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-2261
Mailing Address - Country:US
Mailing Address - Phone:330-455-3873
Mailing Address - Fax:330-455-3934
Practice Address - Street 1:3300 PARKWAY ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-3832
Practice Address - Country:US
Practice Address - Phone:330-454-3471
Practice Address - Fax:330-454-6371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0809227Medicaid