Provider Demographics
NPI:1588643530
Name:FAUSTER CAMERON INC., DBA DEFIANCE CLINIC
Entity Type:Organization
Organization Name:FAUSTER CAMERON INC., DBA DEFIANCE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-784-1414
Mailing Address - Street 1:1400 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2440
Mailing Address - Country:US
Mailing Address - Phone:419-784-1414
Mailing Address - Fax:
Practice Address - Street 1:1400 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2440
Practice Address - Country:US
Practice Address - Phone:419-784-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0429560001Medicare NSC