Healthcare Provider Details

I. General information

NPI: 1205864162
Provider Name (Legal Business Name): HEALTHSOURCE OF OHIO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 STERN RD
SEAMAN OH
45679-9607
US

IV. Provider business mailing address

424 WARDS CORNER RD STE 200
LOVELAND OH
45140-6966
US

V. Phone/Fax

Practice location:
  • Phone: 937-386-1379
  • Fax: 937-386-0129
Mailing address:
  • Phone: 137-074-0415
  • Fax: 513-576-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH W PRATHER II
Title or Position: CEO
Credential: MD
Phone: 513-707-4041