Provider Demographics
NPI:1720734734
Name:SHRADER, VIVA A
Entity type:Individual
Prefix:
First Name:VIVA
Middle Name:A
Last Name:SHRADER
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 1:117 E BROADWAY ST LOT 28
Mailing Address - Street 2:
Mailing Address - City:FORT RECOVERY
Mailing Address - State:OH
Mailing Address - Zip Code:45846-9318
Mailing Address - Country:US
Mailing Address - Phone:937-569-1136
Mailing Address - Fax:
Practice Address - Street 1:1324 SWEITZER ST LOT C3
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-3324
Practice Address - Country:US
Practice Address - Phone:937-548-3962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant