Provider Demographics
NPI:1982887170
Name:SAGE HOLISTIC HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:SAGE HOLISTIC HEALTH SERVICES, LLC
Other - Org Name:SAGE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ZACHARY
Authorized Official - Last Name:ZADER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-253-1234
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:OH
Mailing Address - Zip Code:43334-0253
Mailing Address - Country:US
Mailing Address - Phone:419-253-1234
Mailing Address - Fax:419-253-1334
Practice Address - Street 1:4560 STATE ROUTE 229
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:OH
Practice Address - Zip Code:43334-0253
Practice Address - Country:US
Practice Address - Phone:419-253-1234
Practice Address - Fax:419-253-1334
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAGE HOLISTIC HEALTH SERVICES,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-11
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU88223Medicare UPIN
OHSA9319131Medicare PIN