=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083468474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TASHAY JOHNNY & ADDIES WAY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2024
-----------------------------------------------------
Last Update Date | 04/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8980 TRIPOLI DR
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45251-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-746-8277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8980 TRIPOLI DR
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45251-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOO
-----------------------------------------------------
Name | MS. CORLISS ANN WEST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-746-8277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------