MEDICARE: LAFAWN DAVIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	2379886	OH

General Provider Information

NPI Number	:	1003074659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAFAWN DAVIS

Provider Business Mailing Address
First Line	:	1872 TAYLOR RD
Second Line	:	1872 TAYLOR RD
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-2829
Country	:	US
Telephone Number	:	216-681-0924
Fax Number	:

Provider Business Practice Location Address
First Line	:	1872 TAYLOR RD
Second Line	:	1872 TAYLOR RD
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-2829
Country	:	US
Telephone Number	:	216-681-0924
Fax Number	:

Authorized Official
Title or Position	:	INDEPENDENT PROVIDER
Name	:	LAFAWN M DAVIS
Credential	:
Telephone Number	:	216-681-0924

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	05/30/2008

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