Healthcare Provider Details

I. General information

NPI: 1417392564
Provider Name (Legal Business Name): HOMETOWN PEDIATRIC CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 MCCARTY LN
JACKSON OH
45640-7019
US

IV. Provider business mailing address

PO BOX 959
JACKSON OH
45640-0959
US

V. Phone/Fax

Practice location:
  • Phone: 740-286-5455
  • Fax: 740-286-6782
Mailing address:
  • Phone: 740-286-5455
  • Fax: 740-286-6782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.003758
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP.9753
License Number StateOH

VIII. Authorized Official

Name: JILL A NEFF
Title or Position: OWNER
Credential: DO
Phone: 740-286-5455