Healthcare Provider Details

I. General information

NPI: 1831602119
Provider Name (Legal Business Name): COUNTY OF PUTNAM OFFICE OF AUDITOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 OTTAWA GLANDORF RD STE 3
OTTAWA OH
45875
US

IV. Provider business mailing address

PO BOX 312
OTTAWA OH
45875-0312
US

V. Phone/Fax

Practice location:
  • Phone: 419-523-4449
  • Fax: 419-523-6328
Mailing address:
  • Phone: 419-523-4449
  • Fax: 419-523-6328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2081H0002X
TaxonomyHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JACINTA EICKHOLT
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 419-523-4449