=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437166824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSEPHINE HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2039 JOSEPHINE BLVD
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44212-4031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-273-5494
-----------------------------------------------------
Fax | 330-273-6199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 791 PEARL RD
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44212-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-273-5494
-----------------------------------------------------
Fax | 330-273-6199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ADMINISTRATOR
-----------------------------------------------------
Name | DENISE T POZDERAC
-----------------------------------------------------
Credential | LNHA
-----------------------------------------------------
Telephone | 330-273-5494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 5210168
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------