Basic Information
| Provider Information | |||||||||
| NPI: | 1104214048 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE VILLAGE NETWORK | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1751 E LONG ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432032045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142538050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1751 E LONG ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432032045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142538050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2014 | ||||||||
| LastUpdateDate: | 12/30/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERS | ||||||||
| AuthorizedOfficialFirstName: | MALISA | ||||||||
| AuthorizedOfficialMiddleName: | DAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6142538050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | S.1450587 | OH | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.