Healthcare Provider Details

I. General information

NPI: 1063901031
Provider Name (Legal Business Name): WANIDA ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2018
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 LINWOOD AVE NW
CANTON OH
44708-5621
US

IV. Provider business mailing address

148 LINWOOD AVE NW
CANTON OH
44708-5621
US

V. Phone/Fax

Practice location:
  • Phone: 330-880-9167
  • Fax:
Mailing address:
  • Phone: 330-880-9167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. VINCENT EDWARD WATTS
Title or Position: CEO
Credential:
Phone: 330-880-9167