Healthcare Provider Details

I. General information

NPI: 1679614671
Provider Name (Legal Business Name): CLUB FOR THE AGES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2007
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1196 W BROAD ST
COLUMBUS OH
43222-1319
US

IV. Provider business mailing address

1196 W BROAD ST
COLUMBUS OH
43222-1319
US

V. Phone/Fax

Practice location:
  • Phone: 614-276-0408
  • Fax: 614-276-0644
Mailing address:
  • Phone: 614-276-0408
  • Fax: 614-276-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD C MULLIGAN
Title or Position: VICE PRESIDENT
Credential:
Phone: 614-570-9795