Healthcare Provider Details

I. General information

NPI: 1740590397
Provider Name (Legal Business Name): SKPR OH 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 10TH ST
PORTSMOUTH OH
45662-4152
US

IV. Provider business mailing address

285 MEDICAL CENTER DR
SEAMAN OH
45679-8006
US

V. Phone/Fax

Practice location:
  • Phone: 937-386-0000
  • Fax: 937-386-0009
Mailing address:
  • Phone: 937-386-0000
  • Fax: 937-386-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number35053209
License Number StateOH

VIII. Authorized Official

Name: PRAKASH B PATEL
Title or Position: SOLE MEMBER/MANAGER
Credential: M.D.
Phone: 937-386-0000