Healthcare Provider Details

I. General information

NPI: 1588262000
Provider Name (Legal Business Name): REBECCA BOTTORF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 MARION AVE
MANSFIELD OH
44903-2052
US

IV. Provider business mailing address

455 MARION AVE
MANSFIELD OH
44903-2052
US

V. Phone/Fax

Practice location:
  • Phone: 419-529-9708
  • Fax:
Mailing address:
  • Phone: 419-529-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: