Healthcare Provider Details

I. General information

NPI: 1154724185
Provider Name (Legal Business Name): STAN SHOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2014
Last Update Date: 10/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SHERWOOD GREEN CT
MASON OH
45040-2257
US

IV. Provider business mailing address

200 SHERWOOD GREEN CT
MASON OH
45040-2257
US

V. Phone/Fax

Practice location:
  • Phone: 513-238-1901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number401199400211
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: