Healthcare Provider Details

I. General information

NPI: 1356308407
Provider Name (Legal Business Name): WESTERN RESERVE PROFESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W MAIN ST
KENT OH
44240-2400
US

IV. Provider business mailing address

PO BOX 951971
CLEVELAND OH
44193-0021
US

V. Phone/Fax

Practice location:
  • Phone: 330-677-3628
  • Fax: 330-677-3626
Mailing address:
  • Phone: 330-548-0080
  • Fax: 330-548-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY ANN SEMANCIK
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 330-677-3628