Healthcare Provider Details

I. General information

NPI: 1184190050
Provider Name (Legal Business Name): WIL EDWARD OVERHOLT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1870 QUAKER WAY
WILMINGTON OH
45177-2473
US

IV. Provider business mailing address

17024 CONNECTOR RD
FREDERICKTOWN OH
43019-9723
US

V. Phone/Fax

Practice location:
  • Phone: 740-398-5925
  • Fax:
Mailing address:
  • Phone: 740-398-5925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: