Healthcare Provider Details

I. General information

NPI: 1063105963
Provider Name (Legal Business Name): LOUIS H PENNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/29/2023
Certification Date: 05/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4436 ELM AVE
BRUNSWICK OH
44212-1108
US

IV. Provider business mailing address

4436 ELM AVE
BRUNSWICK OH
44212-1108
US

V. Phone/Fax

Practice location:
  • Phone: 330-416-7888
  • Fax:
Mailing address:
  • Phone: 330-416-7888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: