Healthcare Provider Details

I. General information

NPI: 1952592198
Provider Name (Legal Business Name): CLARK COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2527 KENTON ST
SPRINGFIELD OH
45505-3352
US

IV. Provider business mailing address

2527 KENTON ST
SPRINGFIELD OH
45505-3352
US

V. Phone/Fax

Practice location:
  • Phone: 937-328-2675
  • Fax:
Mailing address:
  • Phone: 937-328-2675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number2568163
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number2566361
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2566361
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number0345184
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number0531679
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number0559613
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number0888848
License Number StateOH
# 8
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number0850155
License Number StateOH
# 9
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2082642
License Number StateOH

VIII. Authorized Official

Name: MR. RAVI SHANKAR
Title or Position: COMPTROLLER
Credential:
Phone: 937-328-2675