=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093250169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIGNATURE HEALTH INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2016
-----------------------------------------------------
Last Update Date | 12/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38882 MENTOR AVE
-----------------------------------------------------
City | WILLOUGHBY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44094-7875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-953-9999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38882 MENTOR AVE.
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JONATHAN LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 440-953-9999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------