=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417430455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LD EDGE NETWORK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2018
-----------------------------------------------------
Last Update Date | 09/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3389 FULTON RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44109-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-870-1432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3389 FULTON RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44109-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-870-1432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | HOLLY LYNN ROE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-870-1432
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------