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General NPI Number Information
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NPI Number | 1740655471
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Entity Type | Organization
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Legal Business Name | SELF
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Dates
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Enumeration Date | 12/07/2015
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Last Update Date | 12/07/2015
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Provider Practice Location Address
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Address Line | 7627 KEY WEST DR
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City | PARMA
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State | OH
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Zip | 44134-6624
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Country | US
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Telephone | 440-539-0929
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Fax |
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Provider Business Mailing Address
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Address Line | 7627 KEY WEST DR
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City | PARMA
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State | OH
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Zip | 44134-6624
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Country | US
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Telephone | 440-539-0929
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | MARY ELIZABETH MOENICH
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Credential | PA-C
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Telephone | 440-539-0929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | 004508
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | 085.005738
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License Number State | IL
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