Provider Demographics
NPI:1043806748
Name:PEGASUS FREEDOM REINS OHIO
Entity type:Organization
Organization Name:PEGASUS FREEDOM REINS OHIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:
Authorized Official - Last Name:REILLY-PANICCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-707-0050
Mailing Address - Street 1:PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43077-0174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16090 HAWN RD
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:OH
Practice Address - Zip Code:43064-9730
Practice Address - Country:US
Practice Address - Phone:937-707-0050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services