Provider Demographics
NPI:1639304991
Name:TOLEDO SPINE & SPORTS MEDICINE
Entity Type:Organization
Organization Name:TOLEDO SPINE & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WALTON
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-270-2774
Mailing Address - Street 1:432 BUTTONWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-3715
Mailing Address - Country:US
Mailing Address - Phone:419-270-2774
Mailing Address - Fax:419-808-8344
Practice Address - Street 1:6444 MONROE ST
Practice Address - Street 2:STE 4
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-1454
Practice Address - Country:US
Practice Address - Phone:419-885-2793
Practice Address - Fax:419-885-3519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies