Provider Demographics
NPI:1427514918
Name:ALPHA & OMEGA SUPPORTED LIVING AGENCY, LLC
Entity type:Organization
Organization Name:ALPHA & OMEGA SUPPORTED LIVING AGENCY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BSBM
Authorized Official - Phone:614-626-8817
Mailing Address - Street 1:2236 S HAMILTON RD STE 104
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-4381
Mailing Address - Country:US
Mailing Address - Phone:614-626-8817
Mailing Address - Fax:614-694-0573
Practice Address - Street 1:1589 BRICE RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2701
Practice Address - Country:US
Practice Address - Phone:614-626-8817
Practice Address - Fax:614-694-0573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0326268Medicaid