Healthcare Provider Details

I. General information

NPI: 1972106862
Provider Name (Legal Business Name): IVEREN MYADZE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2020
Last Update Date: 11/21/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 CHARLESWORTH DR
HUBER HEIGHTS OH
45424-3256
US

IV. Provider business mailing address

PO BOX 24423
HUBER HEIGHTS OH
45424-0423
US

V. Phone/Fax

Practice location:
  • Phone: 937-607-8845
  • Fax:
Mailing address:
  • Phone: 937-607-8845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: