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General NPI Number Information
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NPI Number | 1003076431
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Entity Type | Organization
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Legal Business Name | OCCMED SOURCE, LLC
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Dates
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Enumeration Date | 06/10/2008
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 174 CURRIE HALL PKWY SUITE D
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City | KENT
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State | OH
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Zip | 44240-4387
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Country | US
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Telephone | 330-548-0086
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Fax | 330-548-0085
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Provider Business Mailing Address
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Address Line | 174 CURRIE HALL PKWY SUITE D
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City | KENT
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State | OH
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Zip | 44240-4387
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Country | US
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Telephone | 330-548-0086
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Fax | 330-548-0085
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | GREGORY A MOTEN
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Credential | D.O.
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Telephone | 330-548-0086
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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