Healthcare Provider Details

I. General information

NPI: 1720494289
Provider Name (Legal Business Name): MARY PRIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY PRIM STNA

II. Dates (important events)

Enumeration Date: 07/06/2014
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 E 146TH ST
CLEVELAND OH
44128-1021
US

IV. Provider business mailing address

428 E 143RD ST APT 22
CLEVELAND OH
44110-1879
US

V. Phone/Fax

Practice location:
  • Phone: 216-296-0179
  • Fax:
Mailing address:
  • Phone: 216-704-7119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number601913700723
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number0081238
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: