Healthcare Provider Details

I. General information

NPI: 1700201118
Provider Name (Legal Business Name): TAMARA M COWANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 02/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9409 EASTON AVE
CLEVELAND OH
44104-5417
US

IV. Provider business mailing address

9409 EASTON AVE
CLEVELAND OH
44104-5417
US

V. Phone/Fax

Practice location:
  • Phone: 216-205-1093
  • Fax:
Mailing address:
  • Phone: 216-205-1093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number400171191002
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number400171191002
License Number StateOH

VIII. Authorized Official

Name: TAMARA M COWANS
Title or Position: STNA
Credential:
Phone: 216-205-1093