Healthcare Provider Details

I. General information

NPI: 1518081231
Provider Name (Legal Business Name): PERRY COUNTY BOARD OF MRDD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 SENIOR DR
NEW LEXINGTON OH
43764-1575
US

IV. Provider business mailing address

601 SENIOR DR
NEW LEXINGTON OH
43764-1575
US

V. Phone/Fax

Practice location:
  • Phone: 740-342-7139
  • Fax: 740-342-1081
Mailing address:
  • Phone: 740-342-7139
  • Fax: 740-342-1081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0780007
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number0780007
License Number StateOH

VIII. Authorized Official

Name: JOHNNA NASH
Title or Position: MEDICAID SERVICES MANAGER
Credential:
Phone: 740-343-7139