MEDICARE: CLASSIC HEALTHCARE SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	1662106	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073773719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLASSIC HEALTHCARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	1105 SCHROCK ROAD SUITE 206
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-1704
Country	:	US
Telephone Number	:	614-848-3900
Fax Number	:	614-848-3901

Provider Business Practice Location Address
First Line	:	1105 SCHROCK ROAD SUITE 206
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-1704
Country	:	US
Telephone Number	:	614-848-3900
Fax Number	:	614-848-3901

Authorized Official
Title or Position	:	CEO
Name	:	MR. EVARISTUS BASIL ITIE
Credential	:
Telephone Number	:	614-848-3900

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	09/02/2016

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