Provider Demographics
NPI:1326110990
Name:DANIELS, JUSTICE (RDMS)
Entity Type:Individual
Prefix:
First Name:JUSTICE
Middle Name:
Last Name:DANIELS
Suffix:
Gender:M
Credentials:RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 ALAN CT
Mailing Address - Street 2:# 333
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-5360
Mailing Address - Country:US
Mailing Address - Phone:859-991-3593
Mailing Address - Fax:859-371-5216
Practice Address - Street 1:34 ALAN CT
Practice Address - Street 2:# 333
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-5360
Practice Address - Country:US
Practice Address - Phone:859-991-3593
Practice Address - Fax:859-371-5216
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH70562174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHID01891Medicare ID - Type Unspecified
KY9372401Medicare ID - Type Unspecified