Provider Demographics
NPI:1548054661
Name:BAN, BOPHA
Entity type:Individual
Prefix:
First Name:BOPHA
Middle Name:
Last Name:BAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6390 FIRETHORN AVE
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-1073
Mailing Address - Country:US
Mailing Address - Phone:740-870-6684
Mailing Address - Fax:
Practice Address - Street 1:6390 FIRETHORN AVE
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-1073
Practice Address - Country:US
Practice Address - Phone:740-870-6684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide