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635 S Trimble Rd Mansfield OH 44906-3419 | |
| (419) 524-2676 | |
| (419) 524-2692 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 635 S Trimble Rd, Mansfield, Ohio |
| Authorized Official Name and Position | Insook Chung (PRESIDENT) |
| Authorized Official Contact | 4195242676 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
635 South Trimble Road Mansfield OH 44906-3419 Ph: (419) 524-2676 | 635 S Trimble Rd Mansfield OH 44906-3419 Ph: (419) 524-2676 |
| NPI Number | 1609900851 |
|---|---|
| Provider Enumeration Date | 03/16/2007 |
| Last Update Date | 03/20/2023 |
| Medicare PECOS PAC ID | 0840198438 |
|---|---|
| Medicare Enrollment ID | O20031219000826 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1609900851 | NPI | - | NPPES |
| 0306734 | Medicaid | OH |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | 34005399 (Ohio) | Primary |
| Provider Name | Juan Penhos |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1164420295 PECOS PAC ID: 5395721039 Enrollment ID: I20040624001555 |
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