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105 Opportunity Way Lagrange OH 44050-9018 | |
(440) 355-4206 | |
(440) 355-4213 |
Full Name | |
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Speciality | Clinic/Center |
Location | 105 Opportunity Way, Lagrange, Ohio |
Authorized Official Name and Position | Kimberly M Ralston (CEO) |
Authorized Official Contact | 4199965119 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Po Box 636573 Cincinnati OH 45263-0001 Ph: (440) 988-1009 | 105 Opportunity Way Lagrange OH 44050-9018 Ph: (440) 355-4206 |
NPI Number | 1306070594 |
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Provider Enumeration Date | 05/04/2009 |
Last Update Date | 06/20/2023 |
Medicare PECOS PAC ID | 5092802389 |
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Medicare Enrollment ID | O20110901000402 |
Identifier | Type | State | Issuer |
---|---|---|---|
1306070594 | NPI | - | NPPES |
0056861 | Medicaid | OH |
Taxonomy | Type | License (State) | Status |
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261QR1300X | Clinic/center - Rural Health | (* (Not Available)) | Primary |