Provider Demographics
NPI:1356699201
Name:TOLLEY, JUSTIN CLARK
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CLARK
Last Name:TOLLEY
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 1:1211 KELLER DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-1662
Mailing Address - Country:US
Mailing Address - Phone:419-612-1331
Mailing Address - Fax:
Practice Address - Street 1:1211 KELLER DR.
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905
Practice Address - Country:US
Practice Address - Phone:419-612-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide