Basic Information
| Provider Information | |||||||||
| NPI: | 1902264476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OHIO INDEPENDENT COLLABORATIVE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24651 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24651 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2016 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | KENT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 3309292685 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.