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General NPI Number Information
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NPI Number | 1720520612
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Entity Type | Organization
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Legal Business Name | WESTSIDE PRIMARY CARE, LLC
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Dates
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Enumeration Date | 11/09/2016
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Last Update Date | 12/14/2016
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Provider Practice Location Address
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Address Line | 4342 HARRISON AVE
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City | CINCINNATI
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State | OH
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Zip | 45211-3322
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Country | US
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Telephone | 513-898-9111
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Fax | 844-519-2824
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Provider Business Mailing Address
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Address Line | 4342 HARRISON AVE
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City | CINCINNATI
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State | OH
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Zip | 45211-3322
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Country | US
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Telephone | 513-898-9111
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Fax | 844-519-2824
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Authorized Official
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Title or Position | BILLING ADMIN.
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Name | MRS. SHANNON DICECCO
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Credential |
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Telephone | 513-898-9111
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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 | 3504319
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License Number State | OH
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