1902424708 NPI number — SHANNON MARIA MANUCHE DPT

Table of content: JEFFREY JAMES MASSART (NPI 1134867716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902424708 NPI number — SHANNON MARIA MANUCHE DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANUCHE
Provider First Name:
SHANNON
Provider Middle Name:
MARIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUNN
Provider Other First Name:
SHANNON
Provider Other Middle Name:
MARIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902424708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6480 HARRISON AVE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45247-7961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-713-1779
Provider Business Mailing Address Fax Number:
513-854-9921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 W WILSON BRIDGE RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORTHINGTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43085-2591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-895-8747
Provider Business Practice Location Address Fax Number:
614-895-8810
Provider Enumeration Date:
07/08/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT018675 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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