=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669188108
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINGSPAN CARE GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2023
-----------------------------------------------------
Last Update Date | 01/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3518 W 25TH ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44109-1951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-741-2241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22001 FAIRMOUNT BLVD
-----------------------------------------------------
City | SHAKER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44118-4819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-932-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL COUNSEL
-----------------------------------------------------
Name | LEIGH HALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-320-8222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------