Healthcare Provider Details

I. General information

NPI: 1043400815
Provider Name (Legal Business Name): THOMAS E GUDAITIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1553 NILES CORTLAND RD SE
WARREN OH
44484-3073
US

IV. Provider business mailing address

1553 NILES CORTLAND RD SE
WARREN OH
44484-3073
US

V. Phone/Fax

Practice location:
  • Phone: 330-505-3515
  • Fax: 330-505-3552
Mailing address:
  • Phone: 330-505-3515
  • Fax: 330-505-3552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3811
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: