Provider Demographics
NPI:1356593107
Name:MOLEDOR, THOMAS R
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:MOLEDOR
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 1:3022 STATE ROUTE 59
Mailing Address - Street 2:LOT B44
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1672
Mailing Address - Country:US
Mailing Address - Phone:330-209-1237
Mailing Address - Fax:
Practice Address - Street 1:3022 STATE ROUTE 59
Practice Address - Street 2:LOT B 44
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1672
Practice Address - Country:US
Practice Address - Phone:330-209-1237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRR280499374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide