=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417724501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLANCA I MEDINA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2023
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21245 LORAIN RD STE 150
-----------------------------------------------------
City | FAIRVIEW PARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44126-2196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-256-7640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21585 CENTER RIDGE RD APT 116
-----------------------------------------------------
City | ROCKY RIVER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44116-3912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-256-7640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 33.024177
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------