1295894525 NPI number — WELLNESSONE OF BOARDMAN

Table of content: (NPI 1295894525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295894525 NPI number — WELLNESSONE OF BOARDMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESSONE OF BOARDMAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295894525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11800 E WASHINGTON ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-543-2099
Provider Business Mailing Address Fax Number:
440-543-2085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
843 BOARDMAN CANFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-543-2097
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WHETSTONE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
440-543-2097

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  82002519 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 111N00000X , with the licence number: 3268 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 111N00000X , with the licence number: 2435 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 111N00000X , with the licence number: 3612 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225100000X , with the licence number: PT011126 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225100000X , with the licence number: PT011128 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)