Basic Information
| Provider Information | |||||||||
| NPI: | 1215905385 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALTA CARE GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 BELMONT AVE. | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445021039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307932487 | ||||||||
| FaxNumber: | 3307435748 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 BELMONT AVE. | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445021039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307932487 | ||||||||
| FaxNumber: | 3307435748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | SHOROKEY | ||||||||
| AuthorizedOfficialFirstName: | JOSPEH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3307932487 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LPCC-S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 0222 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 2846657 | 05 | OH | MEDICAID |