Healthcare Provider Details

I. General information

NPI: 1033303987
Provider Name (Legal Business Name): AVENUE TO INDEPENDENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 ROSLYN AVE SW
CANTON OH
44710-1907
US

IV. Provider business mailing address

1021 ROSLYN AVE SW
CANTON OH
44710-1907
US

V. Phone/Fax

Practice location:
  • Phone: 330-454-8719
  • Fax:
Mailing address:
  • Phone: 330-454-8719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number7603856
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number7603856
License Number StateOH

VIII. Authorized Official

Name: MR. DAVID MARTIN MIDAY
Title or Position: C.E.O.
Credential:
Phone: 330-933-2316