Healthcare Provider Details

I. General information

NPI: 1790997773
Provider Name (Legal Business Name): HEALTHSPAN INTEGRATED CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SEVERANCE CIR
CLEVELAND HEIGHTS OH
44118-1533
US

IV. Provider business mailing address

5420 LANCASTER DR
BROOKLYN HEIGHTS OH
44131-1832
US

V. Phone/Fax

Practice location:
  • Phone: 216-297-3803
  • Fax: 216-297-2769
Mailing address:
  • Phone: 216-749-8408
  • Fax: 216-749-8426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number02033850
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number020033850
License Number StateOH

VIII. Authorized Official

Name: MELANIE B ROLSEN
Title or Position: MGR, PHARM BUSINESS
Credential: RPH
Phone: 216-778-6050