Provider Demographics
NPI:1699983775
Name:LAWRENCE COUNTY BOARD OF MENTAL RETARDATION DEVELOPMENT DISABILITIES
Entity type:Organization
Organization Name:LAWRENCE COUNTY BOARD OF MENTAL RETARDATION DEVELOPMENT DISABILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOLLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-532-7401
Mailing Address - Street 1:604 CARLTON DAVIDSON LN
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:604 CARLTON DAVIDSON LN
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2926
Practice Address - Country:US
Practice Address - Phone:740-532-7401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0773042251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0642399Medicaid