Healthcare Provider Details

I. General information

NPI: 1659104172
Provider Name (Legal Business Name): TIFFANY MARIE KACZOR CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22639 EUCLID AVE
EUCLID OH
44117-1622
US

IV. Provider business mailing address

6393 EDGEHURST DR
BROOKPARK OH
44142-3721
US

V. Phone/Fax

Practice location:
  • Phone: 216-404-1900
  • Fax:
Mailing address:
  • Phone: 216-408-7278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.189596
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: