Healthcare Provider Details

I. General information

NPI: 1982806253
Provider Name (Legal Business Name): WALTER EDWARD FLEAK LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2161 VANATTA RD
CENTERBURG OH
43011-9444
US

IV. Provider business mailing address

2161 VANATTA RD
CENTERBURG OH
43011-9444
US

V. Phone/Fax

Practice location:
  • Phone: 740-504-4451
  • Fax:
Mailing address:
  • Phone: 740-504-4451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33-008037
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: