Organization
419-647-4584.
Active
Parent organization
NO
Organization subpart
Yes
Provider details
NPI number
Legal business name
NO
Authorized official
CATHY BATES (STUDENT)
(419) 647-9999
Entity
Organization
Contact information
Practice address
102 S BROADWAY ST, SPENCERVILLE, OH 45887-1267
(614) 582-9253
Mailing address
102 S BROADWAY ST, SPENCERVILLE, OH 45887-1267
Taxonomy
Speciality
Code
Description
License number
State
305S00000X
Point of Service
Primary
788776765655
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
574184689203
—
OH
Enumeration date
01/23/2011
Last updated
01/23/2011
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