Healthcare Provider Details

I. General information

NPI: 1174084859
Provider Name (Legal Business Name): MEGAN MICHELLE PACK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN MICHELLE VALENTINE PTA

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 E POWELL RD
LEWIS CENTER OH
43035-8619
US

IV. Provider business mailing address

1270 E POWELL RD
LEWIS CENTER OH
43035-8619
US

V. Phone/Fax

Practice location:
  • Phone: 614-981-2065
  • Fax:
Mailing address:
  • Phone: 614-981-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number1437540069
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: