Healthcare Provider Details

I. General information

NPI: 1639164205
Provider Name (Legal Business Name): PORTAGE COUNTY BOARD OF DEVELOPMENTAL DISABILIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7008 STATE ROUTE 88
RAVENNA OH
44266-9188
US

IV. Provider business mailing address

2606 BRADY LAKE RD
RAVENNA OH
44266-1604
US

V. Phone/Fax

Practice location:
  • Phone: 330-296-2839
  • Fax: 330-297-8875
Mailing address:
  • Phone: 330-297-6209
  • Fax: 330-297-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0776129
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number2560072
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number2560072
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number2560072
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2560072
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number2560072
License Number StateOH
# 8
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number2560072
License Number StateOH
# 9
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number2560072
License Number StateOH

VIII. Authorized Official

Name: MR. OMAR NAGI
Title or Position: SUPERINTENDENT
Credential:
Phone: 330-297-6209