Healthcare Provider Details

I. General information

NPI: 1235904343
Provider Name (Legal Business Name): TODD WILLIAM OLTHOF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ERIE INDUSTRIAL PARK BLDG 360
PORT CLINTON OH
43452-9412
US

IV. Provider business mailing address

6348 WILMINGTON DR
NORTON SHORES MI
49444-7893
US

V. Phone/Fax

Practice location:
  • Phone: 419-635-2853
  • Fax:
Mailing address:
  • Phone: 231-780-7402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number3201001350
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: