Healthcare Provider Details

I. General information

NPI: 1588765929
Provider Name (Legal Business Name): HARRY T MATHIVHA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 E MARIETTA RD
MCCONNELSVILLE OH
43756-9768
US

IV. Provider business mailing address

103 ARBORGATE DR
MARIETTA OH
45750-9224
US

V. Phone/Fax

Practice location:
  • Phone: 740-962-2152
  • Fax:
Mailing address:
  • Phone: 740-962-2152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberOT.003354
License Number StateOH

VIII. Authorized Official

Name: MR. HARRY TSHIFHIWA MATHIVHA
Title or Position: OWNER
Credential: OTR/L
Phone: 740-962-2152