=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053894063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | -
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2018
-----------------------------------------------------
Last Update Date | 09/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 188 36TH ST SW
-----------------------------------------------------
City | BARBERTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44203-7317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-603-0224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2672 RUBLE DR
-----------------------------------------------------
City | WOOSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44691-7909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-603-0224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MICHELLE RENEE PRICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-603-0224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------