Healthcare Provider Details

I. General information

NPI: 1568349272
Provider Name (Legal Business Name): TWELVE SIXTYTHREE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 NEWBERRY AVE
CLEVELAND OH
44121-3447
US

IV. Provider business mailing address

1003 NEWBERRY AVE
CLEVELAND OH
44121-3447
US

V. Phone/Fax

Practice location:
  • Phone: 440-295-4319
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: CHARMAINE ROSS
Title or Position: OWNER
Credential:
Phone: 216-577-6562