Provider Demographics
NPI:1275674194
Name:WESTERN STARK MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:WESTERN STARK MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:MSS,MAC,LSW,EVCIII
Authorized Official - Phone:330-834-1546
Mailing Address - Street 1:820 AMHERST RD NE
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-8525
Mailing Address - Country:US
Mailing Address - Phone:330-834-1546
Mailing Address - Fax:330-834-1548
Practice Address - Street 1:820 AMHERST RD NE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-8525
Practice Address - Country:US
Practice Address - Phone:330-834-1546
Practice Address - Fax:330-834-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH194251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2369726Medicaid