Provider Demographics
NPI:1649208620
Name:LIVINGSTON LOCKBOURNE AVE FAMILY HEALTH CENTER
Entity type:Organization
Organization Name:LIVINGSTON LOCKBOURNE AVE FAMILY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:D
Authorized Official - Last Name:RATLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:MSA
Authorized Official - Phone:614-252-0917
Mailing Address - Street 1:1289 E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2838
Mailing Address - Country:US
Mailing Address - Phone:614-252-0917
Mailing Address - Fax:614-252-6153
Practice Address - Street 1:1289 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2838
Practice Address - Country:US
Practice Address - Phone:614-252-0917
Practice Address - Fax:614-252-6153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0559417Medicaid
OH71454OtherAETNA HMO ID
OHCM09933OtherRAILROAD
OH71454OtherAETNA HMO ID
OH0559417Medicaid