Healthcare Provider Details

I. General information

NPI: 1104539915
Provider Name (Legal Business Name): OMAR I STEVENS-RIOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3567 CANTERBURY RD
WESTLAKE OH
44145-5406
US

IV. Provider business mailing address

3567 CANTERBURY RD
WESTLAKE OH
44145-5406
US

V. Phone/Fax

Practice location:
  • Phone: 440-506-2600
  • Fax:
Mailing address:
  • Phone: 440-506-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: