Provider Demographics
NPI:1346419066
Name:STATE ROAD OCCUPATIONAL MEDICAL FACILITY LLC
Entity type:Organization
Organization Name:STATE ROAD OCCUPATIONAL MEDICAL FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCVOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-992-9521
Mailing Address - Street 1:600 STATE RD
Mailing Address - Street 2:SUITE 166
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-3933
Mailing Address - Country:US
Mailing Address - Phone:440-992-9521
Mailing Address - Fax:
Practice Address - Street 1:600 STATE RD
Practice Address - Street 2:SUITE 166
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3933
Practice Address - Country:US
Practice Address - Phone:440-992-9521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty