Healthcare Provider Details

I. General information

NPI: 1710724042
Provider Name (Legal Business Name): MS. SUGAR RAE DYKES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10717 DREXEL AVE
CLEVELAND OH
44108-3606
US

IV. Provider business mailing address

10717 DREXEL AVE
CLEVELAND OH
44108-3606
US

V. Phone/Fax

Practice location:
  • Phone: 216-647-5547
  • Fax:
Mailing address:
  • Phone: 216-647-5547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberRS882593
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: