=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780083162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY MCLEOD-BETHUNE INTERVENTION & ENRICHMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2014
-----------------------------------------------------
Last Update Date | 08/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 271 HEDGES ST
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44902-8611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-545-4021
-----------------------------------------------------
Fax | 419-529-3488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5503
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44901-5503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-545-4021
-----------------------------------------------------
Fax | 419-529-3488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHERYL LOVELY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-545-5041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 705115
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------