=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083897060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH PROFESSIONALS OF HOLMES COUNTY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2007
-----------------------------------------------------
Last Update Date | 03/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 153 N. BROADWAY STREET
-----------------------------------------------------
City | SUGARCREEK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-852-2504
-----------------------------------------------------
Fax | 330-763-2063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 981 WOOSTER RD
-----------------------------------------------------
City | MILLERSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44654-1536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-674-1015
-----------------------------------------------------
Fax | 330-763-2063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. JASON JUSTUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-674-1015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------