Healthcare Provider Details

I. General information

NPI: 1295581338
Provider Name (Legal Business Name): COURTNEY L BOWERMASTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 04/29/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 E SECOND ST
FRANKLIN OH
45005
US

IV. Provider business mailing address

5893 S DIXIE HWY
FRANKLIN OH
45005-4362
US

V. Phone/Fax

Practice location:
  • Phone: 937-704-0809
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberOP.017743-S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: