Healthcare Provider Details

I. General information

NPI: 1699986620
Provider Name (Legal Business Name): WESTERN RESERVE PROFESSIONAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 WEST MAIN STREET SUITE C
KENT OH
44240-2400
US

IV. Provider business mailing address

PO BOX 715479
COLUMBUS OH
43271-5479
US

V. Phone/Fax

Practice location:
  • Phone: 330-677-3628
  • Fax: 330-677-4931
Mailing address:
  • Phone: 330-677-3628
  • Fax: 330-677-4931

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 TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: RACHELLE ANN LIGHT
Title or Position: OFFICE COORDINATOR
Credential:
Phone: 330-677-3628