Provider Demographics
NPI:1780083162
Name:MARY MCLEOD-BETHUNE INTERVENTION & ENRICHMENT CENTER
Entity type:Organization
Organization Name:MARY MCLEOD-BETHUNE INTERVENTION & ENRICHMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-545-5041
Mailing Address - Street 1:PO BOX 5503
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44901-5503
Mailing Address - Country:US
Mailing Address - Phone:419-545-4021
Mailing Address - Fax:419-529-3488
Practice Address - Street 1:271 HEDGES ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902-8611
Practice Address - Country:US
Practice Address - Phone:419-545-4021
Practice Address - Fax:419-529-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH705115343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2764469Medicaid