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General NPI Number Information
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NPI Number | 1164003463
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Entity Type | Individual
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Provider Name | MRS. CLARA GRACON
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Gender | Female
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Dates
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Enumeration Date | 04/19/2021
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Last Update Date | 04/19/2021
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Provider Practice Location Address
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Address Line | 2323 BROADVIEW RD
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City | CLEVELAND
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State | OH
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Zip | 44109-4177
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Country | US
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Telephone | 216-661-5077
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Fax |
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Provider Business Mailing Address
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Address Line | 1508 AMBERLEY AVE
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City | CLEVELAND
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State | OH
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Zip | 44109-3504
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Country | US
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Telephone | 216-789-3961
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156F00000X
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Taxonomy Name | Technician/Technologist
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License Number | 09201502
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License Number State | OH
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