MEDICARE: CENTRAL OHIO GROUP HOMES, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	4210642	OH

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	:	1639172463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL OHIO GROUP HOMES, INC.

Provider Business Mailing Address
First Line	:	25000 COUNTRY CLUB BLVD
Second Line	:	SUITE 255
City	:	NORTH OLMSTED
State	:	OH
Zip	:	44070-5344
Country	:	US
Telephone Number	:	440-614-0160
Fax Number	:	440-614-0168

Provider Business Practice Location Address
First Line	:	80 MILLER ST
Second Line	:
City	:	CENTERBURG
State	:	OH
Zip	:	43011-9741
Country	:	US
Telephone Number	:	740-625-6873
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN COLLERAN
Credential	:
Telephone Number	:	440-614-0160

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	06/16/2014

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