Healthcare Provider Details

I. General information

NPI: 1902173701
Provider Name (Legal Business Name): SOLE PROPRIETORSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 CLEARCREEK FRANKLIN RD APT 11
SPRINGBORO OH
45066-9348
US

IV. Provider business mailing address

45 CLEARCREEK FRANKLIN RD APT 11
SPRINGBORO OH
45066-9348
US

V. Phone/Fax

Practice location:
  • Phone: 937-746-1682
  • Fax:
Mailing address:
  • Phone: 937-746-1682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number354649
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. AZELE NIKUZE
Title or Position: REGISTERED NURSE
Credential:
Phone: 937-746-1682