MEDICARE: N/A

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	305R00000X	Preferred Provider Organization	401616630214	OH

General Provider Information

NPI Number	:	1932513694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	N/A

Provider Business Mailing Address
First Line	:	8722 BECKMAN AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-2337
Country	:	US
Telephone Number	:	216-937-9110
Fax Number	:

Provider Business Practice Location Address
First Line	:	8722 BECKMAN AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-2337
Country	:	US
Telephone Number	:	216-937-9110
Fax Number	:

Authorized Official
Title or Position	:	STNA
Name	:	CHRISTINA YVETTE BLAKE
Credential	:
Telephone Number	:	216-937-9110

Provider Enumeration Date	:	06/19/2014
Last Update Date	:	06/19/2014

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