Healthcare Provider Details

I. General information

NPI: 1013159839
Provider Name (Legal Business Name): LABRADOR CONSTRUCTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 BISHOP RD
HIGHLAND HTS OH
44143-1908
US

IV. Provider business mailing address

627 BISHOP RD
HIGHLAND HTS OH
44143-1908
US

V. Phone/Fax

Practice location:
  • Phone: 216-390-1115
  • Fax:
Mailing address:
  • Phone: 216-390-1115
  • Fax: 216-432-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: GARY GILLENWATER
Title or Position: PRESIDENT
Credential:
Phone: 216-390-1115