Basic Information
| Provider Information | |||||||||
| NPI: | 1003070459 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN RESERVE O & P CENTRE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2235 E. PERSHING STREET | ||||||||
| Address2: | SUITE E | ||||||||
| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303378333 | ||||||||
| FaxNumber: | 3303378373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 SOUTH ARCH AVENUE | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308211000 | ||||||||
| FaxNumber: | 3308211924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | GROPE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 3307926826 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN RESERVE O & P CENTRE INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | ZZZ9ZZ5 | 05 | OH | MEDICAID |