Provider Demographics
NPI:1962647180
Name:KROUSE-EVANS, INC.
Entity type:Organization
Organization Name:KROUSE-EVANS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:EBERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-782-7950
Mailing Address - Street 1:245 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-4604
Mailing Address - Country:US
Mailing Address - Phone:419-782-7950
Mailing Address - Fax:419-782-8880
Practice Address - Street 1:245 STADIUM DR
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-4604
Practice Address - Country:US
Practice Address - Phone:419-782-7950
Practice Address - Fax:419-782-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300133851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0415250Medicaid