Healthcare Provider Details

I. General information

NPI: 1417052812
Provider Name (Legal Business Name): JOHN REDRICK INDALECIO OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4604 SAWMILL RD
COLUMBUS OH
43220-2247
US

IV. Provider business mailing address

4604 SAWMILL RD
COLUMBUS OH
43220-2247
US

V. Phone/Fax

Practice location:
  • Phone: 614-827-8700
  • Fax: 614-827-8701
Mailing address:
  • Phone: 614-827-8700
  • Fax: 614-827-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT011046
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT011046
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: