Provider Demographics
NPI:1023600400
Name:BROWN, RICHARD ALAN (VP OF IDD, COO)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALAN
Last Name:BROWN
Suffix:
Gender:M
Credentials:VP OF IDD, COO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 SUNNYSIDE ST SW
Mailing Address - Street 2:
Mailing Address - City:HARTVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44632-9087
Mailing Address - Country:US
Mailing Address - Phone:330-877-7700
Mailing Address - Fax:330-877-7701
Practice Address - Street 1:640 MENLO PARK ST SW
Practice Address - Street 2:
Practice Address - City:HARTVILLE
Practice Address - State:OH
Practice Address - Zip Code:44632-9698
Practice Address - Country:US
Practice Address - Phone:330-877-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7601796320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2274140Medicaid