Healthcare Provider Details

I. General information

NPI: 1801001029
Provider Name (Legal Business Name): VIVIAN A CONDE OTR L CST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41640 PARSONS RD
LAGRANGE OH
44050-9513
US

IV. Provider business mailing address

PO BOX 228
GRAFTON OH
44044-0228
US

V. Phone/Fax

Practice location:
  • Phone: 440-355-8032
  • Fax: 440-355-4230
Mailing address:
  • Phone: 440-355-8032
  • Fax: 440-355-4230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number1133
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: