MEDICARE: MS. DELORES BRATLEY KINNEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	18467412	OH

General Provider Information

NPI Number	:	1063647139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DELORES BRATLEY KINNEY

Provider Business Mailing Address
First Line	:	975 E 141ST ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-3478
Country	:	US
Telephone Number	:	216-854-8412
Fax Number	:

Provider Business Practice Location Address
First Line	:	3660 E 103RD ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44105-2452
Country	:	US
Telephone Number	:	216-854-8412
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2009
Last Update Date	:	05/19/2009

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