Healthcare Provider Details

I. General information

NPI: 1598796716
Provider Name (Legal Business Name): MRS. JANENE MUSGROVE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 COURTNEY DR APT A
DAYTON OH
45431-1288
US

IV. Provider business mailing address

1001 COURTNEY DR APT A
DAYTON OH
45431-1288
US

V. Phone/Fax

Practice location:
  • Phone: 608-443-6646
  • Fax: 937-221-9364
Mailing address:
  • Phone: 608-443-6646
  • Fax: 937-221-9364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: