Healthcare Provider Details

I. General information

NPI: 1417761966
Provider Name (Legal Business Name): CHANEL A CHEATWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9527 PLYMOUTH AVE
GARFIELD HEIGHTS OH
44125-2366
US

IV. Provider business mailing address

9527 PLYMOUTH AVE
GARFIELD HEIGHTS OH
44125-2366
US

V. Phone/Fax

Practice location:
  • Phone: 216-256-1264
  • Fax:
Mailing address:
  • Phone: 216-256-1264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: