Provider Demographics
NPI:1619283504
Name:TIFFIN CONVENIENT CARE LLC
Entity Type:Organization
Organization Name:TIFFIN CONVENIENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MURRAY
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:567-230-6671
Mailing Address - Street 1:2495 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8450
Mailing Address - Country:US
Mailing Address - Phone:567-230-6671
Mailing Address - Fax:
Practice Address - Street 1:2495 W MARKET ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8450
Practice Address - Country:US
Practice Address - Phone:567-230-6671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35064725261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1588671895OtherINDIVIDUAL NPI