Healthcare Provider Details

I. General information

NPI: 1174670285
Provider Name (Legal Business Name): DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 W BROAD ST
COLUMBUS OH
43222-1054
US

IV. Provider business mailing address

30 E BROAD ST
COLUMBUS OH
43215-3414
US

V. Phone/Fax

Practice location:
  • Phone: 614-272-0509
  • Fax: 614-272-1054
Mailing address:
  • Phone: 614-466-1970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number2514097
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number2514097
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number2514097
License Number StateOH

VIII. Authorized Official

Name: D MICHAEL SNOW
Title or Position: SUPERINTENDENT
Credential:
Phone: 614-272-0509