=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821263476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIGNATURE HEALTH SERVICES OF MANSFIELD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2008
-----------------------------------------------------
Last Update Date | 04/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2830 COPLEY RD SUITE 5
-----------------------------------------------------
City | COPLEY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44321-2142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-666-3810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1092 LEXINGTON AVE
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44907-2250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-589-5921
-----------------------------------------------------
Fax | 419-589-5871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. JACK D GOLDSBERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-666-3810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 2535448
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------