Healthcare Provider Details

I. General information

NPI: 1174948418
Provider Name (Legal Business Name): LOUIS DEMICCO DO INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 MENTOR AVE
PAINESVILLE OH
44077-3105
US

IV. Provider business mailing address

263 MENTOR AVE
PAINESVILLE OH
44077-3105
US

V. Phone/Fax

Practice location:
  • Phone: 440-354-5643
  • Fax: 440-354-5645
Mailing address:
  • Phone: 440-354-5643
  • Fax: 440-354-5645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number233
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number012350
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number34006748
License Number StateOH

VIII. Authorized Official

Name: MRS. CINDY LEE PRUZINSKY
Title or Position: CLAIMS PROCESSER
Credential:
Phone: 440-354-5643