Healthcare Provider Details

I. General information

NPI: 1356199137
Provider Name (Legal Business Name): MARK ALLATZAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 05/08/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 FOUNTAIN VIEW ST NE
CANTON OH
44721-3154
US

IV. Provider business mailing address

1240 FOUNTAIN VIEW ST NE
CANTON OH
44721-3154
US

V. Phone/Fax

Practice location:
  • Phone: 330-704-7352
  • Fax:
Mailing address:
  • Phone: 330-704-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: