| NPI | 1942332069 |
|---|---|
| Former Legal Business Name | MEDICAID PRIVATE PROVIDER |
| Entity Type | Organization |
| Authorized Contact | RENEE LOUISE CANNING License Practical Nurse 614-860-9307 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization (Licence: OH RP008385) |
| Enumeration Date | 2007-03-12 |
| Last Update Date | 2008-03-24 |