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General NPI Number Information
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NPI Number | 1275154569
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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 | 04/28/2020
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Last Update Date | 04/28/2020
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Provider Practice Location Address
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Address Line | 353 W MAIN ST
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City | PORTAGE
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State | OH
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Zip | 43451-9802
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Country | US
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Telephone | 419-686-6031
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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 | 43402-2784
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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 | CEO
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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 | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number |
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License Number State |
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