Healthcare Provider Details

I. General information

NPI: 1417693300
Provider Name (Legal Business Name): ANTONIO SCOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13201 GRANGER RD STE 8
CLEVELAND OH
44125-1979
US

IV. Provider business mailing address

1801 WATERMARK DR
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 216-378-3906
  • Fax:
Mailing address:
  • Phone: 614-438-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberRS892339
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: