MEDICARE: COLUMBUS URBAN LEAGUE

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	251K00000X	Public Health or Welfare Agency		OH

General Provider Information

NPI Number	:	1255494845
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBUS URBAN LEAGUE

Provider Business Mailing Address
First Line	:	788 MOUNT VERNON AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43203-1408
Country	:	US
Telephone Number	:	614-257-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	788 MOUNT VERNON AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43203-1408
Country	:	US
Telephone Number	:	614-257-6300
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR, EDUCATION & PREVENTION
Name	:	MR. O'VELL K. HARRISON
Credential	:
Telephone Number	:	614-257-6300

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	08/22/2020

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