Organization
STATE OF OHIO OFFICE OF BUDGET AND MANAGEMENT, STATE ACCOUNTING
Active
Other names
NB - Lake Residential Support CSN
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TONYA MARIE FASONE (FISCAL MANAGER)
(614) 466-9930
Entity
Organization
Contact information
Practice address
1420 LOST NATION RD, WILLOUGHBY, OH 44094-7375
(330) 467-7131
(330) 467-2420
Mailing address
30 E. BROAD ST, 11TH FLOOR - FISCAL ADMINISTRATION, COLUMBUS, OH 43215-3430
(614) 466-6583
(614) 644-5331
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
—
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10409
MACSIS
OH
Enumeration date
03/14/2006
Last updated
11/30/2011
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