Provider Demographics
NPI:1174391072
Name:MAVIS, WESTON
Entity type:Individual
Prefix:
First Name:WESTON
Middle Name:
Last Name:MAVIS
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 1:19940 COUNTY ROAD 25A
Mailing Address - Street 2:
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-7729
Mailing Address - Country:US
Mailing Address - Phone:567-356-6064
Mailing Address - Fax:
Practice Address - Street 1:19940 COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-7729
Practice Address - Country:US
Practice Address - Phone:567-356-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHHPC374U00000X
OHHCP374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide