Healthcare Provider Details

I. General information

NPI: 1134038292
Provider Name (Legal Business Name): MOUNTAGA TALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6992 LAUREL BOAT LN
CANAL WINCHESTER OH
43110-7833
US

IV. Provider business mailing address

6992 LAUREL BOAT LN
CANAL WINCHESTER OH
43110-7833
US

V. Phone/Fax

Practice location:
  • Phone: 216-340-7532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: