Healthcare Provider Details

I. General information

NPI: 1063626885
Provider Name (Legal Business Name): MARY CECELIA PILCK LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17623 EASTON RD
SALESVILLE OH
43778-9878
US

IV. Provider business mailing address

13778 FINLEY RD
SENECAVILLE OH
43780-9731
US

V. Phone/Fax

Practice location:
  • Phone: 740-489-5576
  • Fax:
Mailing address:
  • Phone: 740-685-3866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN 065568
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: