Provider Demographics
NPI:1538614995
Name:MARQUETTA K BUSH
Entity type:Organization
Organization Name:MARQUETTA K BUSH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSING ASSISTANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARQUETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-225-8414
Mailing Address - Street 1:2017 BAKEWELL ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43605-1203
Mailing Address - Country:US
Mailing Address - Phone:567-225-8414
Mailing Address - Fax:419-698-4909
Practice Address - Street 1:2017 BAKEWELL ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-1203
Practice Address - Country:US
Practice Address - Phone:567-225-8414
Practice Address - Fax:419-698-4909
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARQUETTA BUSH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363110231289E251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0157530Medicare PIN