Provider Demographics
NPI:1326436510
Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Other - Org Name:LICKING MEMORIAL ORTHOPEDIC DME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:220-564-4000
Mailing Address - Street 1:1717 W MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1347
Mailing Address - Country:US
Mailing Address - Phone:220-564-2900
Mailing Address - Fax:220-564-2901
Practice Address - Street 1:1717 W MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1347
Practice Address - Country:US
Practice Address - Phone:220-564-2900
Practice Address - Fax:220-564-2901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LICKING MEMORIAL PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-23
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty