Healthcare Provider Details

I. General information

NPI: 1093776775
Provider Name (Legal Business Name): PC ON BOARD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3134 E STATE ST
FREMONT OH
43420-9280
US

IV. Provider business mailing address

3134 E STATE ST
FREMONT OH
43420-9280
US

V. Phone/Fax

Practice location:
  • Phone: 419-332-3911
  • Fax: 419-332-3820
Mailing address:
  • Phone: 419-332-3911
  • Fax: 419-332-3820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberMTB-1051
License Number StateOH

VIII. Authorized Official

Name: MRS. LAUREY C MEDVICK-TATE
Title or Position: OWNER
Credential:
Phone: 419-332-3911