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General NPI Number Information
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NPI Number | 1558705921
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Entity Type | Organization
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Legal Business Name | STATELINE REGIONAL THERAPIST
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Dates
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Enumeration Date | 04/29/2013
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Last Update Date | 04/29/2013
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Provider Practice Location Address
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Address Line | 630 LIBERTY AVE
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City | WEST COLLEGE CORNER
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State | IN
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Zip | 47003-9308
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Country | US
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Telephone | 513-259-0906
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Fax | 765-732-4112
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Provider Business Mailing Address
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Address Line | 630 LIBERTY AVE
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City | WEST COLLEGE CORNER
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State | IN
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Zip | 47003-9308
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Country | US
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Telephone | 513-259-0906
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Fax | 765-732-4112
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Authorized Official
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Title or Position | OWNER
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Name | MRS. DANA R HUNTINGTON
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Credential |
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Telephone | 513-259-0906
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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