Healthcare Provider Details

I. General information

NPI: 1750066460
Provider Name (Legal Business Name): MIDWEST COMMUNITY SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3516 HARRISON AVE
CINCINNATI OH
45211-5595
US

IV. Provider business mailing address

6812 TARAWA DR
CINCINNATI OH
45224-1100
US

V. Phone/Fax

Practice location:
  • Phone: 513-557-8020
  • Fax:
Mailing address:
  • Phone: 513-557-8020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SIRA SOUMARE
Title or Position: DOO
Credential:
Phone: 513-557-8020