Healthcare Provider Details

I. General information

NPI: 1194892133
Provider Name (Legal Business Name): THERESA M.HOM DO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGH ST SUITE I
WORTHINGTON OH
43085-4044
US

IV. Provider business mailing address

1000 HIGH ST SUITE I
WORTHINGTON OH
43085-4044
US

V. Phone/Fax

Practice location:
  • Phone: 614-840-0380
  • Fax: 614-840-0385
Mailing address:
  • Phone: 614-840-0380
  • Fax: 614-840-0385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-004010
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number34-004010
License Number StateOH

VIII. Authorized Official

Name: DR. THERESA M HOM
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 614-840-0380