Healthcare Provider Details

I. General information

NPI: 1063822989
Provider Name (Legal Business Name): PISP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 S HIGH ST
COLUMBUS OH
43207-1045
US

IV. Provider business mailing address

1430 S HIGH ST
COLUMBUS OH
43207-1045
US

V. Phone/Fax

Practice location:
  • Phone: 614-517-0213
  • Fax: 614-444-5342
Mailing address:
  • Phone: 614-517-0213
  • Fax: 614-444-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number3735
License Number StateOH

VIII. Authorized Official

Name: DR. AJAY SYAM
Title or Position: MANAGER
Credential: DC
Phone: 614-517-0213