Healthcare Provider Details

I. General information

NPI: 1215925383
Provider Name (Legal Business Name): STAUSH OAK CASS DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 GLEN DR
MILLERSBURG OH
44654-8958
US

IV. Provider business mailing address

1245 GLEN DR
MILLERSBURG OH
44654-8958
US

V. Phone/Fax

Practice location:
  • Phone: 330-674-0444
  • Fax: 330-674-0802
Mailing address:
  • Phone: 330-674-0444
  • Fax: 330-674-0802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1969
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: