MEDICARE: AM4ZLLC

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1518649995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AM4ZLLC

Provider Business Mailing Address
First Line	:	1958 BURROUGHS DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-4418
Country	:	US
Telephone Number	:	614-290-0033
Fax Number	:

Provider Business Practice Location Address
First Line	:	1958 BURROUGHS DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-4418
Country	:	US
Telephone Number	:	614-290-0033
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SA'JAE EVERHART
Credential	:	LPN
Telephone Number	:	614-290-0033

Provider Enumeration Date	:	08/03/2023
Last Update Date	:	08/03/2023

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Directions to “AM4ZLLC ” Practice Location

Language	Start Address	Practice Location

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