Healthcare Provider Details

I. General information

NPI: 1699715482
Provider Name (Legal Business Name): ANGEL BUTLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20251 FULLER AVE
EUCLID OH
44123-2636
US

IV. Provider business mailing address

20251 FULLER AVE
EUCLID OH
44123-2636
US

V. Phone/Fax

Practice location:
  • Phone: 216-255-1613
  • Fax:
Mailing address:
  • Phone: 216-255-1613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number376865411097
License Number StateOH

VIII. Authorized Official

Name: MS. ANGEL PATRICE BUTLER
Title or Position: NURSING ASST
Credential: STNA
Phone: 216-692-1079