Basic Information
| Provider Information | |||||||||
| NPI: | 1437365947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | C & D MCCLUSKY LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIRACLE-EAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3725 CLEVELAND MASSILLON RD | ||||||||
| Address2: | |||||||||
| City: | NORTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442035614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307060446 | ||||||||
| FaxNumber: | 3307060465 | ||||||||
| Practice Location | |||||||||
| Address1: | 3725 CLEVELAND MASSILLON RD | ||||||||
| Address2: | |||||||||
| City: | NORTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442035614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307060446 | ||||||||
| FaxNumber: | 3307060465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCLUSKY | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3307060446 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 2075 | OH | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 000000155889 | 01 | OH | ANTHEM PIN # | OTHER | 7670683 | 01 | OH | AETNA PIN # | OTHER |