Healthcare Provider Details

I. General information

NPI: 1982054458
Provider Name (Legal Business Name): HISPANIC UMADAOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 PRAME AVE
CLEVELAND OH
44109
US

IV. Provider business mailing address

384 PROSPECT ST.
BEREA OH
44017
US

V. Phone/Fax

Practice location:
  • Phone: 440-876-7806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number120988
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number120988
License Number StateOH

VIII. Authorized Official

Name: MR. VICTOR OWEN PHILLIPS
Title or Position: COUNSELOR/CASE MANAGER
Credential: CDCA
Phone: 216-351-3833