Provider Demographics
NPI:1558677047
Name:JUSTICE, THOMAS P (LPN: CSFA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:LPN: CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 E CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-2209
Mailing Address - Country:US
Mailing Address - Phone:513-797-4920
Mailing Address - Fax:
Practice Address - Street 1:1926 E CONCORD RD
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-2209
Practice Address - Country:US
Practice Address - Phone:513-797-4920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO102799246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant