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General NPI Number Information
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NPI Number | 1215029525
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Entity Type | Organization
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Legal Business Name | WOOD LANE RESIDENTIAL SERVICES, INC.
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Dates
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Enumeration Date | 09/28/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 349 W MAIN ST.
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City | PORTAGE
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State | OH
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Zip | 43451
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Country | US
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Telephone | 419-353-9577
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Fax |
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Provider Business Mailing Address
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Address Line | 545 PEARL ST
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City | BOWLING GREEN
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State | OH
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Zip | 43402-2731
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Country | US
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Telephone | 419-353-9577
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | JESSICA BLAKELY
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Credential |
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Telephone | 419-353-9577
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number |
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License Number State | OH
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