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General NPI Number Information
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NPI Number | 1265910293
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Entity Type | Individual
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Provider Name | MARTIN PHILLIP MIRISE NURSE AIDE
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Gender | Male
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Dates
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Enumeration Date | 08/01/2018
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Last Update Date | 08/01/2018
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Provider Practice Location Address
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Address Line | 1725-14TH ST. S.W.
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City | CANTON
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State | OH
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Zip | 44706-5247
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Country | US
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Telephone | 330-454-8440
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Fax |
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Provider Business Mailing Address
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Address Line | 1725-14TH ST. S.W.
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City | CANTON
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State | OH
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Zip | 44706-5247
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Country | US
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Telephone | 330-454-8440
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number | ODAPROV539434899
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 376K00000X
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Taxonomy Name | Nurse's Aide
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License Number | 400765940608
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License Number State | OH
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