Provider Demographics
NPI:1821217308
Name:INDEPENDENT PROVIDER
Entity Type:Organization
Organization Name:INDEPENDENT PROVIDER
Other - Org Name:INDEPENDENT PROVIDER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INDEPENDENT PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CAPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-324-4438
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:S CHARLESTON
Mailing Address - State:OH
Mailing Address - Zip Code:45368-0427
Mailing Address - Country:US
Mailing Address - Phone:937-324-4438
Mailing Address - Fax:
Practice Address - Street 1:2273 NEWLOVE RD
Practice Address - Street 2:
Practice Address - City:S CHARLESTON
Practice Address - State:OH
Practice Address - Zip Code:45368-9732
Practice Address - Country:US
Practice Address - Phone:937-324-4438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSK307751302F00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered302F00000XManaged Care OrganizationsExclusive Provider Organization
Not Answered305R00000XManaged Care OrganizationsPreferred Provider Organization