Basic Information
| Provider Information | |||||||||
| NPI: | 1275602542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARION WALDO CHIROPRACTIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1448 MARION WALDO RD | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433027422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403866580 | ||||||||
| FaxNumber: | 7403866586 | ||||||||
| Practice Location | |||||||||
| Address1: | 491 E CENTER ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433024244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403866580 | ||||||||
| FaxNumber: | 7403866586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | THARP | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7403866580 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 3431 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 000000334224 | 01 | OH | ANTHEM | OTHER | 27588480600 | 01 | OH | WORKERS COMPENSATION | OTHER | 2493832 | 05 | OH | MEDICAID | 275884806001 | 01 | OH | MEDICAL MUTUAL | OTHER | 2484084 | 05 | OH | MEDICAID | 27588332600 | 01 | OH | WORKERS COMPENSATION | OTHER | 275883326001 | 01 | OH | MEDICAL MUTUAL | OTHER | 000000334225 | 01 | OH | ANTHEM | OTHER |