=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245809904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTER SEALS NORTHERN OHIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2021
-----------------------------------------------------
Last Update Date | 06/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1907 CROGHAN ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-2762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-589-6834
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1212 PORTAGE TRL
-----------------------------------------------------
City | CUYAHOGA FALLS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44223-2128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 234-417-0250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | LAUREN E HOLLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 234-417-0250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------