Healthcare Provider Details

I. General information

NPI: 1093883712
Provider Name (Legal Business Name): MR. EVERISTUS BASIL ITIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 BUSCH CT
COLUMBUS OH
43229-1704
US

IV. Provider business mailing address

788 BUSCH CT
COLUMBUS OH
43229-1704
US

V. Phone/Fax

Practice location:
  • Phone: 614-848-3900
  • Fax: 614-848-3901
Mailing address:
  • Phone: 614-848-3900
  • Fax: 614-848-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: