Provider Demographics
NPI:1710694799
Name:WEAVER, JUSTIN LEE (PROVIDER)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEE
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 ORCHARDGLOW CLOSE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-3164
Mailing Address - Country:US
Mailing Address - Phone:513-600-9170
Mailing Address - Fax:
Practice Address - Street 1:904 ORCHARDGLOW CLOSE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-3164
Practice Address - Country:US
Practice Address - Phone:513-600-9170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant