Provider Demographics
NPI:1033650163
Name:INDEPENDENT PROVIDER
Entity type:Organization
Organization Name:INDEPENDENT PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:L'OREAL
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-303-4144
Mailing Address - Street 1:288 E 248TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:288 E 248TH ST
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-1437
Practice Address - Country:US
Practice Address - Phone:216-303-4144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP841892320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities