Healthcare Provider Details

I. General information

NPI: 1962455196
Provider Name (Legal Business Name): OHIO SPORTS & SPINE INSTITUTE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4004
US

IV. Provider business mailing address

1265 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4004
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-9400
  • Fax: 330-726-8676
Mailing address:
  • Phone: 330-758-9400
  • Fax: 330-726-8676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberOH34004337
License Number StateOH

VIII. Authorized Official

Name: LAURIE KLEEH
Title or Position: PRACTICE MANAGER
Credential: CPA
Phone: 330-758-9400