Healthcare Provider Details

I. General information

NPI: 1083067896
Provider Name (Legal Business Name): JAZ CICERO SANTANA BOYCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: EIJAZ KAYTENNAE SHABAZZ EL

II. Dates (important events)

Enumeration Date: 07/16/2016
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3118 HOUSTON DR
COLUMBUS OH
43207-3398
US

IV. Provider business mailing address

3118 HOUSTON DR
COLUMBUS OH
43207-3398
US

V. Phone/Fax

Practice location:
  • Phone: 614-407-6352
  • Fax:
Mailing address:
  • Phone: 614-407-6352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: