Healthcare Provider Details

I. General information

NPI: 1417058009
Provider Name (Legal Business Name): PHYSICIANS DIAGNOSTIC & REHABILITATION CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 TRAILWOOD DR
BOARDMAN OH
44512-5007
US

IV. Provider business mailing address

914 TRAILWOOD DR
BOARDMAN OH
44512-5007
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-6440
  • Fax: 330-758-6990
Mailing address:
  • Phone: 330-758-6440
  • Fax: 330-758-6990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2426
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number34.002093
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2533
License Number StateOH

VIII. Authorized Official

Name: MARIA IGNAZIO
Title or Position: OFFICE MANAGER
Credential:
Phone: 330-758-6440