MEDICARE: PHENOMENALLY YOURS HEALTHCARE LLC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1184353740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHENOMENALLY YOURS HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	964 BRUNSWICK RD
Second Line	:
City	:	CLEVELAND HTS
State	:	OH
Zip	:	44112-2315
Country	:	US
Telephone Number	:	216-551-6494
Fax Number	:

Provider Business Practice Location Address
First Line	:	964 BRUNSWICK RD
Second Line	:
City	:	CLEVELAND HTS
State	:	OH
Zip	:	44112-2315
Country	:	US
Telephone Number	:	216-551-6494
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	THEODORIA SMITH
Credential	:
Telephone Number	:	216-551-6494

Provider Enumeration Date	:	06/08/2022
Last Update Date	:	06/08/2022

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