Healthcare Provider Details

I. General information

NPI: 1053858464
Provider Name (Legal Business Name): JONATHAN M OLLINGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S OHIO AVE SUITE B
SIDNEY OH
45365-3112
US

IV. Provider business mailing address

402 S OHIO AVE SUITE B
SIDNEY OH
45365-3112
US

V. Phone/Fax

Practice location:
  • Phone: 937-726-4983
  • Fax:
Mailing address:
  • Phone: 937-726-4983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.013078
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: