Provider Demographics
NPI:1801001029
Name:CONDE, VIVIAN A (OTR L CST)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:A
Last Name:CONDE
Suffix:
Gender:F
Credentials:OTR L CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:OH
Mailing Address - Zip Code:44044-0228
Mailing Address - Country:US
Mailing Address - Phone:440-355-8032
Mailing Address - Fax:440-355-4230
Practice Address - Street 1:41640 PARSONS RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:OH
Practice Address - Zip Code:44050-9513
Practice Address - Country:US
Practice Address - Phone:440-355-8032
Practice Address - Fax:440-355-4230
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1133111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341605134OtherCOMMERCIAL INSURANCE
OH341605134-01OtherBWC
OH341605134005OtherMEDICAL MUTUAL OF OHIO
OH341605134OtherCOMMERCIAL INSURANCE