Provider Demographics
NPI:1992136279
Name:NORTH COAST PROFESSIONAL COMPANY, LLC
Entity type:Organization
Organization Name:NORTH COAST PROFESSIONAL COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHRIVER
Authorized Official - Suffix:
Authorized Official - Credentials:HCMBA, CPA
Authorized Official - Phone:419-557-5540
Mailing Address - Street 1:1031 PIERCE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4669
Mailing Address - Country:US
Mailing Address - Phone:419-557-5541
Mailing Address - Fax:419-557-5542
Practice Address - Street 1:1470 WEST MCPHERSON HIGHWAY
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:OH
Practice Address - Zip Code:43410
Practice Address - Country:US
Practice Address - Phone:419-557-5541
Practice Address - Fax:419-557-5542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2021707Medicaid
OH2021707Medicaid