Healthcare Provider Details

I. General information

NPI: 1922064864
Provider Name (Legal Business Name): DAVID JOHN OHRT DMIN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 W LINCOLNWAY ST
JEFFERSON IA
50129-1671
US

IV. Provider business mailing address

110 E STATE ST
JEFFERSON IA
50129-1953
US

V. Phone/Fax

Practice location:
  • Phone: 515-386-4662
  • Fax:
Mailing address:
  • Phone: 515-386-4817
  • Fax: 515-386-4847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number00796
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: