Provider Demographics
NPI:1578161394
Name:KIRTS, ROBERTA JEAN
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:JEAN
Last Name:KIRTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5266 STATE ROUTE 38 NW
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-9534
Mailing Address - Country:US
Mailing Address - Phone:740-708-0665
Mailing Address - Fax:
Practice Address - Street 1:5266 STATE ROUTE 38 NW
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-9534
Practice Address - Country:US
Practice Address - Phone:740-708-0665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0096463Medicaid