MEDICARE: EBONY CHANEL ERVIN

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	253Z00000X	In Home Supportive Care Agency	1829445	OH

General Provider Information

NPI Number	:	1730781527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY CHANEL ERVIN

Provider Business Mailing Address
First Line	:	14201 KENNERDOWN AVE
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-3625
Country	:	US
Telephone Number	:	216-338-4181
Fax Number	:

Provider Business Practice Location Address
First Line	:	14201 KENNERDOWN AVE
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-3625
Country	:	US
Telephone Number	:	216-338-4181
Fax Number	:

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

Provider Enumeration Date	:	11/16/2020
Last Update Date	:	11/16/2020

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