Healthcare Provider Details

I. General information

NPI: 1174166516
Provider Name (Legal Business Name): SOARING ON SUCCESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 SOUTH AVE LOT 55
TOLEDO OH
43615-6445
US

IV. Provider business mailing address

5001 SOUTH AVE LOT 55
TOLEDO OH
43615-6445
US

V. Phone/Fax

Practice location:
  • Phone: 419-705-8682
  • Fax:
Mailing address:
  • Phone: 419-705-8682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. DWAYNE LEE GIBSON JR.
Title or Position: CEO
Credential:
Phone: 419-705-8682