MEDICARE: INDEPENDENT PROVIDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305R00000X	Preferred Provider Organization	SK307751	OH
2	302F00000X	Exclusive Provider Organization	SK307751	OH

General Provider Information

NPI Number	:	1821217308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT PROVIDER

Provider Business Mailing Address
First Line	:	PO BOX 427
Second Line	:
City	:	S CHARLESTON
State	:	OH
Zip	:	45368-0427
Country	:	US
Telephone Number	:	937-324-4438
Fax Number	:

Provider Business Practice Location Address
First Line	:	2273 NEWLOVE RD
Second Line	:
City	:	S CHARLESTON
State	:	OH
Zip	:	45368-9732
Country	:	US
Telephone Number	:	937-324-4438
Fax Number	:

Authorized Official
Title or Position	:	INDEPENDENT PROVIDER
Name	:	MRS. WENDY SUE CAPPER
Credential	:
Telephone Number	:	937-324-4438

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	09/11/2025

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Directions to “INDEPENDENT PROVIDER ” Practice Location

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