Provider Demographics
NPI:1811026453
Name:VILLAGE OF ROSEVILLE
Entity type:Organization
Organization Name:VILLAGE OF ROSEVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:KEYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-252-8078
Mailing Address - Street 1:PO BOX 392907
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251
Mailing Address - Country:US
Mailing Address - Phone:800-962-1484
Mailing Address - Fax:
Practice Address - Street 1:9 W 1ST ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43777
Practice Address - Country:US
Practice Address - Phone:740-342-9367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0739697Medicaid
OH000000155272OtherANTHEM
OH0739697Medicaid