Healthcare Provider Details

I. General information

NPI: 1588398366
Provider Name (Legal Business Name): GRO COMMUNITY OHIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6809 MAIN ST # 1038
CINCINNATI OH
45244-3470
US

IV. Provider business mailing address

259 E 115TH ST
CHICAGO IL
60628-5014
US

V. Phone/Fax

Practice location:
  • Phone: 773-253-8385
  • Fax:
Mailing address:
  • Phone: 773-253-8385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: AARON MALLORY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 773-253-8385