Provider Demographics
NPI:1285754994
Name:CHAMPAIGN COUNTY
Entity type:Organization
Organization Name:CHAMPAIGN COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:BSN RN
Authorized Official - Phone:937-484-1619
Mailing Address - Street 1:1512 S US HIGHWAY 68
Mailing Address - Street 2:SUITE Q100
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-9198
Mailing Address - Country:US
Mailing Address - Phone:937-484-1605
Mailing Address - Fax:937-484-1622
Practice Address - Street 1:1512 S US HIGHWAY 68
Practice Address - Street 2:SUITE Q100
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-9198
Practice Address - Country:US
Practice Address - Phone:937-484-1605
Practice Address - Fax:937-484-1622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034599251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2410699Medicaid
OHFV94341Medicare ID - Type UnspecifiedFLU ROSTER BILLING NUMBER
OH2410699Medicaid