Healthcare Provider Details

I. General information

NPI: 1518733120
Provider Name (Legal Business Name): ANTHONY THREATS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2624 LEXINGTON AVE
SPRINGFIELD OH
45505-2620
US

IV. Provider business mailing address

2624 LEXINGTON AVE
SPRINGFIELD OH
45505-2620
US

V. Phone/Fax

Practice location:
  • Phone: 937-328-5300
  • Fax: 937-322-4900
Mailing address:
  • Phone: 937-328-5300
  • Fax: 937-322-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.186004
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: