Provider Demographics
NPI:1518554211
Name:STORY, THEODORE ALLEN JR
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:ALLEN
Last Name:STORY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 METZGER HILL RD SW
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43837-9269
Mailing Address - Country:US
Mailing Address - Phone:330-204-3016
Mailing Address - Fax:
Practice Address - Street 1:3633 METZGER HILL RD SW
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43837-9269
Practice Address - Country:US
Practice Address - Phone:330-204-3016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3143137Medicaid