MEDICARE: HEALING TRAILS, 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	251S00000X	Community/Behavioral Health Agency	111018	OH

General Provider Information

NPI Number	:	1295167757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALING TRAILS, LLC

Provider Business Mailing Address
First Line	:	143 COUNTY ROAD 242
Second Line	:
City	:	FREMONT
State	:	OH
Zip	:	43420-9234
Country	:	US
Telephone Number	:	419-552-0647
Fax Number	:

Provider Business Practice Location Address
First Line	:	4317 STATE ROUTE 269 S
Second Line	:
City	:	CASTALIA
State	:	OH
Zip	:	44824-9354
Country	:	US
Telephone Number	:	419-684-9750
Fax Number	:

Authorized Official
Title or Position	:	COUNSELOR
Name	:	CARRIE TORRES
Credential	:	LCDCIII
Telephone Number	:	419-552-0647

Provider Enumeration Date	:	08/06/2013
Last Update Date	:	08/06/2013

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