=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689077125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELF-EMPLOYED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2014
-----------------------------------------------------
Last Update Date | 09/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95B BARLEY DR
-----------------------------------------------------
City | PAINESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44077-5349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-251-9701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95B BARLEY DR
-----------------------------------------------------
City | PAINESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44077-5349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-251-9701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STNA
-----------------------------------------------------
Name | DELMESHA JACKSON
-----------------------------------------------------
Credential | HOMEHEALTH
-----------------------------------------------------
Telephone | 440-251-9701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number | 47
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------