Healthcare Provider Details

I. General information

NPI: 1629731757
Provider Name (Legal Business Name): ONLINE DOCTOR OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N GOULD ST STE N
SHERIDAN WY
82801-6317
US

IV. Provider business mailing address

30 N GOULD ST STE N
SHERIDAN WY
82801-6317
US

V. Phone/Fax

Practice location:
  • Phone: 800-222-9375
  • Fax: 740-738-0707
Mailing address:
  • Phone: 800-222-9375
  • Fax: 740-738-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: MR. TERRY LEWIS
Title or Position: CIO
Credential:
Phone: 304-639-9809