MEDICARE: CUMBERLAND RESIDENTIAL CARE, 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1346993508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUMBERLAND RESIDENTIAL CARE, LLC

Provider Business Mailing Address
First Line	:	1845 EMERSON AVE APT D3
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-4804
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1845 EMERSON AVE APT D3
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-4804
Country	:	US
Telephone Number	:	207-274-1596
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALINE MWAMIKAZI
Credential	:
Telephone Number	:	207-274-1596

Provider Enumeration Date	:	01/28/2022
Last Update Date	:	01/28/2022

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