Healthcare Provider Details

I. General information

NPI: 1174234868
Provider Name (Legal Business Name): MICHEAL DAVID GRAVES LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 BELMONT AVE.
YOUNGSTOWN OH
44504
US

IV. Provider business mailing address

1815 BELMONT AVE.
YOUNGSTOWN OH
44504
US

V. Phone/Fax

Practice location:
  • Phone: 330-740-9200
  • Fax:
Mailing address:
  • Phone: 330-740-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.092670.MEDS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: