Provider Demographics
NPI:1669129219
Name:OHIO GROUP HOME OF MIDDLETOWN LLC
Entity type:Organization
Organization Name:OHIO GROUP HOME OF MIDDLETOWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURDERDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-205-6813
Mailing Address - Street 1:1 EXECUTIVE BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4157
Mailing Address - Country:US
Mailing Address - Phone:845-205-6813
Mailing Address - Fax:
Practice Address - Street 1:3100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-7421
Practice Address - Country:US
Practice Address - Phone:845-205-6813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children