Healthcare Provider Details

I. General information

NPI: 1821217308
Provider Name (Legal Business Name): INDEPENDENT PROVIDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2273 NEWLOVE RD
S CHARLESTON OH
45368-9732
US

IV. Provider business mailing address

PO BOX 427
S CHARLESTON OH
45368-0427
US

V. Phone/Fax

Practice location:
  • Phone: 937-324-4438
  • Fax:
Mailing address:
  • Phone: 937-324-4438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberSK307751
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberSK307751
License Number StateOH

VIII. Authorized Official

Name: MRS. WENDY SUE CAPPER
Title or Position: INDEPENDENT PROVIDER
Credential:
Phone: 937-324-4438