Provider Demographics
NPI:1508037847
Name:WALDEN PONDS MEDICAL CARE LLC
Entity Type:Organization
Organization Name:WALDEN PONDS MEDICAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-893-1100
Mailing Address - Street 1:5964 GOLF CLUB LN
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-8224
Mailing Address - Country:US
Mailing Address - Phone:513-893-1100
Mailing Address - Fax:513-893-1128
Practice Address - Street 1:5964 GOLF CLUB LN
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-8224
Practice Address - Country:US
Practice Address - Phone:513-893-1100
Practice Address - Fax:513-893-1128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081138A207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35081138AOtherSTATE LICENSE
OH35081138AOtherSTATE LICENSE
OHI10208Medicare UPIN