=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932657152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PORTAGE INDUSTRIES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2016
-----------------------------------------------------
Last Update Date | 09/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 785 N FREEDOM ST
-----------------------------------------------------
City | RAVENNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44266-2469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-839-8671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7008 STATE ROUTE 88
-----------------------------------------------------
City | RAVENNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44266-9188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-296-3996
-----------------------------------------------------
Fax | 330-296-8875
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. PHILIP MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-296-3996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | 3008051
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------