Healthcare Provider Details

I. General information

NPI: 1508037847
Provider Name (Legal Business Name): WALDEN PONDS MEDICAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5964 GOLF CLUB LN
HAMILTON OH
45011-8224
US

IV. Provider business mailing address

5964 GOLF CLUB LN
HAMILTON OH
45011-8224
US

V. Phone/Fax

Practice location:
  • Phone: 513-893-1100
  • Fax: 513-893-1128
Mailing address:
  • Phone: 513-893-1100
  • Fax: 513-893-1128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35081138A
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35081138A
License Number StateOH

VIII. Authorized Official

Name: MRS. SHAWNA M HELTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 513-893-1100