Healthcare Provider Details

I. General information

NPI: 1356831788
Provider Name (Legal Business Name): ERNEST BANKS CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 NEBRASKA AVE
TOLEDO OH
43615-4632
US

IV. Provider business mailing address

PO BOX 20068
TOLEDO OH
43610-0068
US

V. Phone/Fax

Practice location:
  • Phone: 419-531-5544
  • Fax: 419-531-5117
Mailing address:
  • Phone: 419-531-5544
  • Fax: 419-531-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.090458
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: