1982887170 NPI number — SAGE HOLISTIC HEALTH SERVICES, LLC

Table of content: (NPI 1982887170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982887170 NPI number — SAGE HOLISTIC HEALTH SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAGE HOLISTIC HEALTH SERVICES, LLC
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:
SAGE CHIROPRACTIC
Provider Other Organization Name Type Code:
3
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:
1982887170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 253
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARENGO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43334-0253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-253-1234
Provider Business Mailing Address Fax Number:
419-253-1334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4560 STATE ROUTE 229
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARENGO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43334-0253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-253-1234
Provider Business Practice Location Address Fax Number:
419-253-1334
Provider Enumeration Date:
12/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ZADER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
ZACHARY
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
419-253-1234

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3147 , 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)





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