Provider Demographics
NPI:1295399046
Name:WILMOTH, EDWARD L
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:L
Last Name:WILMOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:RITTMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44270-1305
Mailing Address - Country:US
Mailing Address - Phone:330-690-8302
Mailing Address - Fax:
Practice Address - Street 1:24 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:RITTMAN
Practice Address - State:OH
Practice Address - Zip Code:44270-1305
Practice Address - Country:US
Practice Address - Phone:330-690-8302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty