Healthcare Provider Details

I. General information

NPI: 1740600964
Provider Name (Legal Business Name): MR. MATT DAPORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 BUCKEYE ST
ROCKFORD OH
45882-9266
US

IV. Provider business mailing address

2968 JERICHO PL
DELAWARE OH
43015-3175
US

V. Phone/Fax

Practice location:
  • Phone: 419-363-2193
  • Fax:
Mailing address:
  • Phone: 614-401-7294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number5096-2
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: