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General NPI Number Information
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NPI Number | 1932513694
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Entity Type | Organization
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Legal Business Name | N/A
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Dates
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Enumeration Date | 06/19/2014
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Last Update Date | 06/19/2014
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Provider Practice Location Address
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Address Line | 8722 BECKMAN AVE
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City | CLEVELAND
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State | OH
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Zip | 44104-2337
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Country | US
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Telephone | 216-937-9110
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Fax |
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Provider Business Mailing Address
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Address Line | 8722 BECKMAN AVE
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City | CLEVELAND
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State | OH
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Zip | 44104-2337
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Country | US
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Telephone | 216-937-9110
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Fax |
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Authorized Official
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Title or Position | STNA
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Name | CHRISTINA YVETTE BLAKE
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Credential |
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Telephone | 216-937-9110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 401616630214
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License Number State | OH
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