Provider Demographics
NPI:1649693789
Name:MICHELLE ROUNDTREE
Entity type:Organization
Organization Name:MICHELLE ROUNDTREE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NON PERSONAL AID
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUNDTREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:418-970-1409
Mailing Address - Street 1:1144 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-1923
Mailing Address - Country:US
Mailing Address - Phone:419-870-1409
Mailing Address - Fax:
Practice Address - Street 1:1144 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43607-1923
Practice Address - Country:US
Practice Address - Phone:419-870-1409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-25
Last Update Date:2014-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHINDIVIDUAL PROVIDERMedicaid