Healthcare Provider Details

I. General information

NPI: 1730912247
Provider Name (Legal Business Name): MICHAEL ALAN JUERGENS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W SILVER ST UNIT B
LEBANON OH
45036-2778
US

IV. Provider business mailing address

210 W SILVER ST UNIT B
LEBANON OH
45036-2778
US

V. Phone/Fax

Practice location:
  • Phone: 513-372-2913
  • Fax:
Mailing address:
  • Phone: 513-372-2913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: