=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316263072
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STOUT SENIOR CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2010
-----------------------------------------------------
Last Update Date | 04/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7843 LAUREL AVE
-----------------------------------------------------
City | MADEIRA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45243-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-432-6468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6118 WELSFORD CT
-----------------------------------------------------
City | MAUMEE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43537-1329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CAY MATEYKO STOUT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-350-8322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------