Healthcare Provider Details

I. General information

NPI: 1336977982
Provider Name (Legal Business Name): MARIO COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LAKE CLUB DR
COLUMBUS OH
43232-3204
US

IV. Provider business mailing address

5615 WELLINGTON WOODS BLVD
COLUMBUS OH
43213-6618
US

V. Phone/Fax

Practice location:
  • Phone: 614-704-5224
  • Fax:
Mailing address:
  • Phone: 614-772-3575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: