MEDICARE: MR. ABDULQAADIR HENRY HENRY

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	172A00000X	Driver

General Provider Information

NPI Number	:	1073082814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ABDULQAADIR HENRY HENRY

Provider Business Mailing Address
First Line	:	4353 OVERLAND PKWY
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43612-2116
Country	:	US
Telephone Number	:	313-212-0394
Fax Number	:	419-407-5748

Provider Business Practice Location Address
First Line	:	4353 OVERLAND PKWY
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43612-2116
Country	:	US
Telephone Number	:	313-212-0394
Fax Number	:	419-407-5748

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

Provider Enumeration Date	:	11/23/2018
Last Update Date	:	11/23/2018

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