=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639769680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIKAS GROUP HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2021
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2611 MONTANA AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45211-3768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-244-1562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 58130
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45258-0130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-244-1562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | TANIKA PRICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-550-7449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------