Healthcare Provider Details

I. General information

NPI: 1386901296
Provider Name (Legal Business Name): MR. CHARLES JOSHUA WACHENSCHWANZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10733 STATE ROUTE 682
THE PLAINS OH
45780-1328
US

IV. Provider business mailing address

10733 STATE ROUTE 682
THE PLAINS OH
45780-1328
US

V. Phone/Fax

Practice location:
  • Phone: 740-856-6731
  • Fax:
Mailing address:
  • Phone: 740-856-6731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberTF824203
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: