Healthcare Provider Details

I. General information

NPI: 1710370309
Provider Name (Legal Business Name): SOUTHWEST CONVENIENCE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 06/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W PLANE ST UNIT 150
BETHEL OH
45106-8339
US

IV. Provider business mailing address

720 W PLANE ST UNIT 150
BETHEL OH
45106-8339
US

V. Phone/Fax

Practice location:
  • Phone: 513-427-4057
  • Fax: 513-427-4051
Mailing address:
  • Phone: 513-427-4057
  • Fax: 513-427-4051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number2371512
License Number StateOH

VIII. Authorized Official

Name: MRS. TRACY DAWN DUNN
Title or Position: OWNER
Credential: CNP
Phone: 513-310-8742