Basic Information
| Provider Information | |||||||||
| NPI: | 1124057914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE VILLAGE NETWORK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 NOBLE DR | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446915353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302643232 | ||||||||
| FaxNumber: | 3302023880 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 NOBLE DR | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446915353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302643232 | ||||||||
| FaxNumber: | 3302023880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAZIANO | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3302643232 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | 0342 | OH | N | Agencies | Voluntary or Charitable | 261QM0801X | 0342 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | 0342 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QR0405X | 13684 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 13685 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 13686 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 320800000X | 0342 | OH | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 251V00000X | Y | Agencies | Voluntary or Charitable |
ID Information
| ID | Type | State | Issuer | Description | 2847147 | 05 | OH | MEDICAID |