Healthcare Provider Details

I. General information

NPI: 1770606535
Provider Name (Legal Business Name): JEANETTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2784 VIOLA ST SW
WARREN OH
44485-3343
US

IV. Provider business mailing address

2784 VIOLA S.T S.W
WARREN OH
44485
US

V. Phone/Fax

Practice location:
  • Phone: 330-898-6413
  • Fax: 330-898-6417
Mailing address:
  • Phone: 330-898-6413
  • Fax: 330-898-6414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. JEANETTA ANN CHATMON I
Title or Position: CARE PROVIDER
Credential:
Phone: 330-898-6413