Healthcare Provider Details

I. General information

NPI: 1043806748
Provider Name (Legal Business Name): PEGASUS FREEDOM REINS OHIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16090 HAWN RD
PLAIN CITY OH
43064-9730
US

IV. Provider business mailing address

PO BOX 174
UNIONVILLE CENTER OH
43077-0174
US

V. Phone/Fax

Practice location:
  • Phone: 937-707-0050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JO REILLY-PANICCIA
Title or Position: OWNER
Credential:
Phone: 937-707-0050