NPI |
1295356574 |
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot
include a Post Office box. |
Entity Type Code |
2 |
The city name in the location address of the provider being identified. |
Employer Identification Number EIN |
|
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
Provider Organization Name Legal Business Name |
E HOME BEHAVIORAL LLC |
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
Provider First Line Business Practice Location Address |
2317 E HOME RD |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
SPRINGFIELD |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address State Name |
OH |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
455032520 |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
5134897100 |
The country code in the location address of the provider being identified. |
Provider Enumeration Date |
4/28/2020 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
4/28/2020 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Authorized Official Last Name |
ROSEDALE |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official First Name |
ISAAC |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official Title or Position |
PRESIDENT |
The title or position of the authorized official. |
Authorized Official Telephone Number |
5134897100 |
The title or position of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
261QR0405X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
N |
|
NPI Certification Date |
4/28/2020 |
|