Healthcare Provider Details

I. General information

NPI: 1760289938
Provider Name (Legal Business Name): MACY VAIL AT
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2025
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 IRVING SCHOTTENSTEIN DR
COLUMBUS OH
43210-1069
US

IV. Provider business mailing address

615 IRVING SCHOTTENSTEIN DR
COLUMBUS OH
43210-1069
US

V. Phone/Fax

Practice location:
  • Phone: 208-430-1397
  • Fax:
Mailing address:
  • Phone: 208-430-1397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT007261
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: