Healthcare Provider Details

I. General information

NPI: 1538343231
Provider Name (Legal Business Name): SANDY VALLEY PROF INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10025 CLEVELAND AVE SE
MAGNOLIA OH
44643-9781
US

IV. Provider business mailing address

PO BOX 419
EAST SPARTA OH
44626-0419
US

V. Phone/Fax

Practice location:
  • Phone: 330-866-3309
  • Fax: 330-866-3077
Mailing address:
  • Phone: 330-866-3309
  • Fax: 330-866-3077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number75313
License Number StateOH

VIII. Authorized Official

Name: FRANCESCA P NICOLETTI
Title or Position: OFFICE MANAGER
Credential:
Phone: 330-866-3309