Healthcare Provider Details

I. General information

NPI: 1831480441
Provider Name (Legal Business Name): VIVIANCE ADULT DAY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 PARK AVE W
MANSFIELD OH
44906-3720
US

IV. Provider business mailing address

454 BROADVIEW AVE
MANSFIELD OH
44903-1946
US

V. Phone/Fax

Practice location:
  • Phone: 419-610-0057
  • Fax:
Mailing address:
  • Phone: 419-610-0057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberRR817269
License Number StateOH

VIII. Authorized Official

Name: MS. EDEISHA E BROOKS
Title or Position: OWNER
Credential:
Phone: 419-610-0057