Healthcare Provider Details

I. General information

NPI: 1306562749
Provider Name (Legal Business Name): S.I.S.T.E.R SISTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12809 CORLETT AVE
CLEVELAND OH
44105-2915
US

IV. Provider business mailing address

12809 CORLETT AVE
CLEVELAND OH
44105-2915
US

V. Phone/Fax

Practice location:
  • Phone: 440-424-0754
  • Fax:
Mailing address:
  • Phone: 440-561-7712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JASMINE JOHNSON
Title or Position: OWNER
Credential:
Phone: 405-617-7124