Healthcare Provider Details

I. General information

NPI: 1093995664
Provider Name (Legal Business Name): OHIO HOME CARE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 JETT ST
WEST PORTSMOUTH OH
45663-6213
US

IV. Provider business mailing address

613 JETT ST
WEST PORTSMOUTH OH
45663-6213
US

V. Phone/Fax

Practice location:
  • Phone: 740-858-2828
  • Fax:
Mailing address:
  • Phone: 740-858-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberPN 113668
License Number StateOH

VIII. Authorized Official

Name: MRS. KAREN ELAINE WALLRT
Title or Position: LPN
Credential: LPN
Phone: 740-858-2828