MEDICARE: MINAMYER RESIDENTIAL MR/DD SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083218390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINAMYER RESIDENTIAL MR/DD SERVICES, INC.

Provider Business Mailing Address
First Line	:	967 WORTHINGTON WOODS LOOP RD
Second Line	:
City	:	WORTHINGTON
State	:	OH
Zip	:	43085-5743
Country	:	US
Telephone Number	:	614-802-0190
Fax Number	:

Provider Business Practice Location Address
First Line	:	967 WORTHINGTON WOODS LOOP RD
Second Line	:
City	:	WORTHINGTON
State	:	OH
Zip	:	43085-5743
Country	:	US
Telephone Number	:	614-802-0190
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DEAN A MINAMYER
Credential	:
Telephone Number	:	614-802-0190

Provider Enumeration Date	:	11/27/2020
Last Update Date	:	11/27/2020

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