1598850059 NPI number — LTC SUPPLY

Table of content: WAYNE MICHAEL CAGLE MED LPC (NPI 1427178292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598850059 NPI number — LTC SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LTC SUPPLY
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:
1598850059
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:
2332 CADWALLADER SONK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORTLAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-637-2330
Provider Business Mailing Address Fax Number:
330-637-2372

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
781 NORTHWEST BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-297-6967
Provider Business Practice Location Address Fax Number:
877-297-7380
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WAID
Authorized Official First Name:
AMY
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
330-637-2330

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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)

  • Identifier: 0218857 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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