Healthcare Provider Details

I. General information

NPI: 1124876313
Provider Name (Legal Business Name): LIVING A DREAM ADULT DAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2024
Last Update Date: 07/07/2024
Certification Date: 07/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9737 RAVENNA RD STE L
TWINSBURG OH
44087-2143
US

IV. Provider business mailing address

2401 DANBURY LN
HUDSON OH
44236-1414
US

V. Phone/Fax

Practice location:
  • Phone: 216-219-2552
  • Fax:
Mailing address:
  • Phone: 216-219-2552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TASHUA LAVONE FORTSON
Title or Position: CEO
Credential:
Phone: 216-219-2552