Provider Demographics
NPI:1639164205
Name:PORTAGE COUNTY BOARD OF DEVELOPMENTAL DISABILIT
Entity type:Organization
Organization Name:PORTAGE COUNTY BOARD OF DEVELOPMENTAL DISABILIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-297-6209
Mailing Address - Street 1:2606 BRADY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1604
Mailing Address - Country:US
Mailing Address - Phone:330-297-6209
Mailing Address - Fax:330-297-1202
Practice Address - Street 1:7008 STATE ROUTE 88
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-9188
Practice Address - Country:US
Practice Address - Phone:330-296-2839
Practice Address - Fax:330-297-8875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTAGE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-20
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH252Y00000X
OH2560072344600000X, 347C00000X, 251K00000X, 251E00000X, 251S00000X, 347B00000X, 251C00000X
OH0776129251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No252Y00000XAgenciesEarly Intervention Provider Agency
No344600000XTransportation ServicesTaxi
No347C00000XTransportation ServicesPrivate Vehicle
No251K00000XAgenciesPublic Health or Welfare
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No347B00000XTransportation ServicesBus
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6700010Medicaid