Provider Demographics
NPI:1104885045
Name:AFRICENTRIC PERSONAL DECELOPMENT SHOP
Entity type:Organization
Organization Name:AFRICENTRIC PERSONAL DECELOPMENT SHOP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-253-4448
Mailing Address - Street 1:1409 E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2926
Mailing Address - Country:US
Mailing Address - Phone:614-253-4448
Mailing Address - Fax:614-253-8781
Practice Address - Street 1:1409 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2926
Practice Address - Country:US
Practice Address - Phone:614-253-4448
Practice Address - Fax:614-253-8781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02915251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH02915Medicare UPIN