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General NPI Number Information
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NPI Number | 1942973367
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Entity Type | Organization
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Legal Business Name | PROVECTUS LTC LLC
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Dates
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Enumeration Date | 07/30/2021
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Last Update Date | 07/30/2021
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Provider Practice Location Address
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Address Line | 300 W SPRING ST UNIT 702
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City | COLUMBUS
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State | OH
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Zip | 43215-7651
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Country | US
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Telephone | 937-402-1000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 609
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City | LUCASVILLE
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State | OH
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Zip | 45648-0609
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Country | US
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Telephone | 937-402-1000
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Fax |
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Authorized Official
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Title or Position | MD
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Name | DR. DIRK N JUSCHKA
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Credential |
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Telephone | 937-402-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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