Healthcare Provider Details

I. General information

NPI: 1285286443
Provider Name (Legal Business Name): ROBERT AILES LAX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 S. CHESTNUT ST.
RAVENNA OH
44266
US

IV. Provider business mailing address

246 S. CHESTNUT ST.
RAVENNA OH
44266
US

V. Phone/Fax

Practice location:
  • Phone: 330-298-9391
  • Fax: 330-298-9392
Mailing address:
  • Phone: 330-298-9391
  • Fax: 330-298-9392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number021208
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: