MEDICARE: INSTITUTE OF YOUTH DEVELOPMENT AND EXCELLENCE

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1912277831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSTITUTE OF YOUTH DEVELOPMENT AND EXCELLENCE

Provider Business Mailing Address
First Line	:	2232 STRATFORD AVE
Second Line	:	STE 220
City	:	CINCINNATI
State	:	OH
Zip	:	45219-1202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2232 STRATFORD AVE
Second Line	:	STE 220
City	:	CINCINNATI
State	:	OH
Zip	:	45219-1202
Country	:	US
Telephone Number	:	513-297-3955
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	RIYAD SHAMMA
Credential	:
Telephone Number	:	513-297-3955

Provider Enumeration Date	:	01/09/2012
Last Update Date	:	01/09/2012

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