Healthcare Provider Details

I. General information

NPI: 1043372485
Provider Name (Legal Business Name): FALLEN TIMBERS CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 PROVIDENCE ST
WHITEHOUSE OH
43571-9273
US

IV. Provider business mailing address

6901 PROVIDENCE ST
WHITEHOUSE OH
43571-9273
US

V. Phone/Fax

Practice location:
  • Phone: 419-877-9919
  • Fax: 419-877-9977
Mailing address:
  • Phone: 419-877-9919
  • Fax: 419-877-9977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1510
License Number StateOH

VIII. Authorized Official

Name: DR. WAYNE F. KOSKINEN
Title or Position: OWNER
Credential: DC
Phone: 419-877-9919