=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801071477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. HENRY COLEMAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2008
-----------------------------------------------------
Last Update Date | 01/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3101 WINCHESTER AVE APT 761
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-2076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-393-5125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3101 WINCHESTER AVE APT 761
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-2076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-393-5125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number | 2732252
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------