Provider Demographics
NPI:1699362665
Name:WENTZ, LORENE MARIE
Entity Type:Individual
Prefix:
First Name:LORENE
Middle Name:MARIE
Last Name:WENTZ
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 1:9061 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087-1757
Mailing Address - Country:US
Mailing Address - Phone:330-998-4812
Mailing Address - Fax:
Practice Address - Street 1:9061 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-1757
Practice Address - Country:US
Practice Address - Phone:330-998-4812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRR240493343900000X, 347C00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7711097OtherWAIVER PROVIDER CONTRACT NUMBER