Provider Demographics
NPI:1679960124
Name:TIM DOUGLASS
Entity type:Organization
Organization Name:TIM DOUGLASS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DRIVER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-485-8529
Mailing Address - Street 1:14060 VINCENT RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-8283
Mailing Address - Country:US
Mailing Address - Phone:740-485-8529
Mailing Address - Fax:
Practice Address - Street 1:14060 VINCENT RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-8283
Practice Address - Country:US
Practice Address - Phone:740-485-8529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRP410135347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle