Healthcare Provider Details

I. General information

NPI: 1124620018
Provider Name (Legal Business Name): SUSANNE D ELSWICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2020
Last Update Date: 11/18/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 TYLER ST
PORT CLINTON OH
43452-2140
US

IV. Provider business mailing address

714 CLINTON ST
PORT CLINTON OH
43452-2116
US

V. Phone/Fax

Practice location:
  • Phone: 419-732-2777
  • Fax:
Mailing address:
  • Phone: 419-341-0294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: