Healthcare Provider Details

I. General information

NPI: 1982647954
Provider Name (Legal Business Name): PROFESSIONALS PRN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 DR. MIKE CLOUSE DRIVE
SOMERSET OH
43783
US

IV. Provider business mailing address

1132 TAYLOR ST
ZANESVILLE OH
43701-2658
US

V. Phone/Fax

Practice location:
  • Phone: 740-743-1590
  • Fax: 740-743-2579
Mailing address:
  • Phone: 740-454-5666
  • Fax: 740-452-7563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number021273150
License Number StateOH

VIII. Authorized Official

Name: MR. ROD B STICKRATH
Title or Position: DIRECTOR
Credential: RPH
Phone: 740-454-5666