Provider Demographics
NPI:1073332243
Name:MCCLAIN, MARIQEZ
Entity type:Individual
Prefix:
First Name:MARIQEZ
Middle Name:
Last Name:MCCLAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 WAGER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:491 GEORGESVILLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-2420
Practice Address - Country:US
Practice Address - Phone:614-618-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-05
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTS34366172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker