=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144278276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MHSWO HEALTH VENTURES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 N LIMESTONE ST SUITE 102
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45503-2665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-399-5303
-----------------------------------------------------
Fax | 937-399-5292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 N LIMESTONE ST SUITE 102
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45503-2665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-399-5303
-----------------------------------------------------
Fax | 937-399-5292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INTERIM PRESIDENT AND CEO
-----------------------------------------------------
Name | MR. JAMES R. GRAVELL JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-325-0531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | N/A
-----------------------------------------------------
License Number State |
-----------------------------------------------------