Healthcare Provider Details

I. General information

NPI: 1992910863
Provider Name (Legal Business Name): INDEPENDENT PROVIDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 W 1ST ST
ARCANUM OH
45304-1167
US

IV. Provider business mailing address

308 W 1ST ST
ARCANUM OH
45304-1167
US

V. Phone/Fax

Practice location:
  • Phone: 937-692-8081
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: DAVID MARTIN FERGUSON
Title or Position: INDEPENDENT
Credential:
Phone: 937-692-8081