Healthcare Provider Details

I. General information

NPI: 1861214488
Provider Name (Legal Business Name): MR. JOHN DATE IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 132
ATHENS OH
45701-0132
US

IV. Provider business mailing address

49 JOHNSON RD
THE PLAINS OH
45780-1146
US

V. Phone/Fax

Practice location:
  • Phone: 740-594-6807
  • Fax: 740-447-9091
Mailing address:
  • Phone: 740-764-4529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: