Provider Demographics
NPI:1306069752
Name:OUR LADY OF THE WAYSIDE
Entity type:Organization
Organization Name:OUR LADY OF THE WAYSIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-934-6007
Mailing Address - Street 1:38135 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-1028
Mailing Address - Country:US
Mailing Address - Phone:440-934-6007
Mailing Address - Fax:440-934-6327
Practice Address - Street 1:38135 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-1028
Practice Address - Country:US
Practice Address - Phone:440-934-6007
Practice Address - Fax:440-934-6327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4700514320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4700514OtherOUR LADY OF THE WAYSIDE