Basic Information
| Provider Information | |||||||||
| NPI: | 1871852582 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE BUCKEYE RANCH, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5665 HOOVER ROAD | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148752371 | ||||||||
| FaxNumber: | 6148752366 | ||||||||
| Practice Location | |||||||||
| Address1: | 5665 HOOVER RD | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431239122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143847798 | ||||||||
| FaxNumber: | 6143847798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2012 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | EVP OF INNOVATIVE CARE & STRATEGIES | ||||||||
| AuthorizedOfficialTelephone: | 6147299415 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 12433 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 2863718 | 01 | OH | OHIO MITS PROVIDER ID | OTHER | 3153/12433 | 01 | OH | STATE OF OHIO MACIL UPI # | OTHER |