Healthcare Provider Details

I. General information

NPI: 1841891827
Provider Name (Legal Business Name): WAYNE MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

898 TOWNSHIP ROAD 210
MARENGO OH
43334-9623
US

IV. Provider business mailing address

898 TOWNSHIP ROAD 210
MARENGO OH
43334-9623
US

V. Phone/Fax

Practice location:
  • Phone: 419-210-4645
  • Fax:
Mailing address:
  • Phone: 419-210-4645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL CLEVELAND
Title or Position: OWNER
Credential:
Phone: 419-210-4649