Basic Information
| Provider Information | |||||||||
| NPI: | 1396771572 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHPRO INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HEALTHPRO HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 950 TAYLOR STATION RD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432306670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148647340 | ||||||||
| FaxNumber: | 6148631771 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 TAYLOR STATION RD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432306670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148647340 | ||||||||
| FaxNumber: | 6148631771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSS | ||||||||
| AuthorizedOfficialFirstName: | ANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6148647340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 2506710 | 05 | OH | MEDICAID |