Basic Information
| Provider Information | |||||||||
| NPI: | 1215526934 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRU CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 W 4TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449061865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199893180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2003 W 4TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449061865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199893180 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2021 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | SWISHER | ||||||||
| AuthorizedOfficialFirstName: | JENNY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 4199893180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CNP | ||||||||
| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0412012 | 05 | OH | MEDICAID |