Provider Demographics
NPI:1902354095
Name:HOPE OF JABEZ
Entity Type:Organization
Organization Name:HOPE OF JABEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROUTH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-957-5268
Mailing Address - Street 1:4068 GANTZ RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-4816
Mailing Address - Country:US
Mailing Address - Phone:614-957-5268
Mailing Address - Fax:614-957-5303
Practice Address - Street 1:4068 GANTZ RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-4816
Practice Address - Country:US
Practice Address - Phone:614-957-5268
Practice Address - Fax:614-957-5303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-17
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008410261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4153721Medicaid
OHRO4153722Medicare PIN
OH4153721Medicaid