Healthcare Provider Details

I. General information

NPI: 1023747581
Provider Name (Legal Business Name): MARK POUCHER III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 E BALDWIN AVE
PAULDING OH
45879-1109
US

IV. Provider business mailing address

418 E BALDWIN AVE
PAULDING OH
45879-1109
US

V. Phone/Fax

Practice location:
  • Phone: 419-769-3708
  • Fax:
Mailing address:
  • Phone: 419-769-3708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: