Healthcare Provider Details

I. General information

NPI: 1912313628
Provider Name (Legal Business Name): PROVIDER HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3832 MONTEVISTA
CLEVELAND PROVINCE
OHIO
GE

IV. Provider business mailing address

3832 MONTEVISTA
CLEVELAND OH
44121
US

V. Phone/Fax

Practice location:
  • Phone: 216-799-1097
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberFDW1871
License Number StateOH

VIII. Authorized Official

Name: PATRICIA RICHARDS
Title or Position: CNA
Credential:
Phone: 216-799-1097