Healthcare Provider Details

I. General information

NPI: 1801189592
Provider Name (Legal Business Name): DR. DIRK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W SPRING ST UNIT 702
COLUMBUS OH
43215-7651
US

IV. Provider business mailing address

PO BOX 609
LUCASVILLE OH
45648-0609
US

V. Phone/Fax

Practice location:
  • Phone: 937-232-8033
  • Fax: 937-426-6576
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number35.052815
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DIRK NORMAN JUSCHKA
Title or Position: CEO
Credential: M.D.
Phone: 937-402-1000