Healthcare Provider Details

I. General information

NPI: 1063416030
Provider Name (Legal Business Name): CENTRAL OHIO GROUP HOMES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 COUNTY ROAD 25
CARDINGTON OH
43315-9346
US

IV. Provider business mailing address

25000 COUNTRY CLUB BLVD SUITE 255
NORTH OLMSTED OH
44070-5344
US

V. Phone/Fax

Practice location:
  • Phone: 419-768-9962
  • Fax:
Mailing address:
  • Phone: 440-614-0160
  • Fax: 440-614-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number5910143
License Number StateOH

VIII. Authorized Official

Name: BRIAN COLLERAN
Title or Position: PRESIDENT
Credential:
Phone: 440-614-0160