Healthcare Provider Details

I. General information

NPI: 1215487400
Provider Name (Legal Business Name): MR. ERNEST NANA AGYEMANG-BOTCHWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 VERSAILLES 87 VERSAILLES
CINCINNATI OH
45240-3826
US

IV. Provider business mailing address

87 VERSAILLES 11100 SPINGFIELD PIKE,CINCINNATI,OHIO 45246
CINCINNATI OH
45240-3826
US

V. Phone/Fax

Practice location:
  • Phone: 513-307-8898
  • Fax:
Mailing address:
  • Phone: 513-307-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number160610
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number160610
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: