MEDICARE: ASHTABULA COUNTY RESIDENTIAL SERVICES CORP.

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	0410013	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	:	1265608756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASHTABULA COUNTY RESIDENTIAL SERVICES CORP.

Provider Business Mailing Address
First Line	:	29 PARRISH RD
Second Line	:
City	:	CONNEAUT
State	:	OH
Zip	:	44030-1146
Country	:	US
Telephone Number	:	440-593-6027
Fax Number	:	440-593-6007

Provider Business Practice Location Address
First Line	:	2956 E CENTER ST
Second Line	:
City	:	N KINGSVILLE
State	:	OH
Zip	:	44068-0361
Country	:	US
Telephone Number	:	440-224-0662
Fax Number	:	440-224-0662

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. DEBORAH L MALOY
Credential	:	RN
Telephone Number	:	440-593-6027

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	05/05/2008

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