Provider Demographics
NPI:1538343231
Name:SANDY VALLEY PROF INC
Entity type:Organization
Organization Name:SANDY VALLEY PROF INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCESCA
Authorized Official - Middle Name:P
Authorized Official - Last Name:NICOLETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-866-3309
Mailing Address - Street 1:PO BOX 419
Mailing Address - Street 2:
Mailing Address - City:EAST SPARTA
Mailing Address - State:OH
Mailing Address - Zip Code:44626-0419
Mailing Address - Country:US
Mailing Address - Phone:330-866-3309
Mailing Address - Fax:330-866-3077
Practice Address - Street 1:10025 CLEVELAND AVE SE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:OH
Practice Address - Zip Code:44643-9781
Practice Address - Country:US
Practice Address - Phone:330-866-3309
Practice Address - Fax:330-866-3077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH75313174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK9914631Medicare PIN