Provider Demographics
NPI:1902802481
Name:COUNTY OF PUTNAM OFFICE OF AUDITOR
Entity Type:Organization
Organization Name:COUNTY OF PUTNAM OFFICE OF AUDITOR
Other - Org Name:PUTNAM COUNTY HOMECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACINTA
Authorized Official - Middle Name:
Authorized Official - Last Name:EICKHOLT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-523-4449
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:OH
Mailing Address - Zip Code:45875-0312
Mailing Address - Country:US
Mailing Address - Phone:419-523-4449
Mailing Address - Fax:419-523-6328
Practice Address - Street 1:575 O-G ROAD SUITE 3
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:OH
Practice Address - Zip Code:45875
Practice Address - Country:US
Practice Address - Phone:419-523-4449
Practice Address - Fax:419-523-6328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
OHNO LICENSE # ISSUED251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0044428Medicaid
OH000000157607OtherANTHEM BCBS
OH0044428OtherBCMH
OH6900143OtherMR/DD
OH=========OtherTAX ID
OH=========-007OtherMEDICAL MUTUAL OF OH
OH0044428Medicaid