Provider Demographics
NPI:1902159494
Name:PERIDOT CARE SERVICES, LLC
Entity Type:Organization
Organization Name:PERIDOT CARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:OCONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-268-2219
Mailing Address - Street 1:270 E KELSO RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-2306
Mailing Address - Country:US
Mailing Address - Phone:614-268-2219
Mailing Address - Fax:614-268-0644
Practice Address - Street 1:270 E KELSO RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-2306
Practice Address - Country:US
Practice Address - Phone:614-268-2219
Practice Address - Fax:614-268-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-21
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH28536253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0063506Medicaid