Provider Demographics
NPI:1790491330
Name:CLAYTOR, INDIA
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:
Last Name:CLAYTOR
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 1:350 S. IRWIN RD.
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528
Mailing Address - Country:US
Mailing Address - Phone:419-222-4474
Mailing Address - Fax:
Practice Address - Street 1:350 S. IRWIN RD.
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528
Practice Address - Country:US
Practice Address - Phone:419-222-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management