Provider Demographics
NPI:1316372550
Name:HOMETOWN ANCILLARY SERVICES LLC
Entity type:Organization
Organization Name:HOMETOWN ANCILLARY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MANOJ
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-505-7602
Mailing Address - Street 1:2400 CORPORATE EXCHANGE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-7605
Mailing Address - Country:US
Mailing Address - Phone:614-505-7633
Mailing Address - Fax:614-847-1106
Practice Address - Street 1:1303 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1920
Practice Address - Country:US
Practice Address - Phone:937-717-4045
Practice Address - Fax:937-717-4811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-06
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
OH35.044048207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0091689Medicaid
OH0091689Medicaid