Healthcare Provider Details

I. General information

NPI: 1548272115
Provider Name (Legal Business Name): WEST SIDE ECUMENICAL MINISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5209 DETROIT AVE
CLEVELAND OH
44102-2224
US

IV. Provider business mailing address

5209 DETROIT AVE
CLEVELAND OH
44102-2224
US

V. Phone/Fax

Practice location:
  • Phone: 216-651-2037
  • Fax: 216-651-4145
Mailing address:
  • Phone: 216-651-2037
  • Fax: 216-651-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0505
License Number StateOH

VIII. Authorized Official

Name: JUDITH PETERS
Title or Position: PRESIDENT/CEO
Credential: R.N.
Phone: 216-651-2037