MEDICARE: HARRY T MATHIVHA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center	OT.003354	OH

General Provider Information

NPI Number	:	1588765929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARRY T MATHIVHA

Provider Business Mailing Address
First Line	:	103 ARBORGATE DR
Second Line	:
City	:	MARIETTA
State	:	OH
Zip	:	45750-9224
Country	:	US
Telephone Number	:	740-962-2152
Fax Number	:

Provider Business Practice Location Address
First Line	:	985 E MARIETTA RD
Second Line	:
City	:	MCCONNELSVILLE
State	:	OH
Zip	:	43756-9768
Country	:	US
Telephone Number	:	740-962-2152
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. HARRY TSHIFHIWA MATHIVHA
Credential	:	OTR/L
Telephone Number	:	740-962-2152

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	06/17/2008

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