MEDICARE: CHIMEREA DE'SHAY PORTER

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	374U00000X	Home Health Aide		OH
2	343900000X	Non-emergency Medical Transport (VAN)		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790282085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHIMEREA DE'SHAY PORTER

Provider Business Mailing Address
First Line	:	16212 KOLLIN AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-3808
Country	:	US
Telephone Number	:	216-456-1530
Fax Number	:

Provider Business Practice Location Address
First Line	:	16212 KOLLIN AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-3808
Country	:	US
Telephone Number	:	216-456-1530
Fax Number	:

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

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	04/12/2018

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