Healthcare Provider Details

I. General information

NPI: 1114218641
Provider Name (Legal Business Name): INDIVIDUAL HOME HEALTH PROVIDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 S HIGH ST
URBANA OH
43078-2513
US

IV. Provider business mailing address

1003 S HIGH ST
URBANA OH
43078-2513
US

V. Phone/Fax

Practice location:
  • Phone: 937-631-5908
  • Fax:
Mailing address:
  • Phone: 937-631-5908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number141729
License Number StateOH

VIII. Authorized Official

Name: MRS. JESSICA ADAMS
Title or Position: LPN
Credential:
Phone: 937-631-5908