Basic Information
| Provider Information | |||||||||
| NPI: | 1982647954 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONALS PRN LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHSIDE OXYGEN & MEDICAL EQUIPMENT PERRY COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1132 TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437012658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404545666 | ||||||||
| FaxNumber: | 7404527563 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 DR. MIKE CLOUSE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407431590 | ||||||||
| FaxNumber: | 7407432579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 01/09/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STICKRATH | ||||||||
| AuthorizedOfficialFirstName: | ROD | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7404545666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 021273150 | OH | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 2380749 | 05 | OH | MEDICAID |