MEDICARE: ST AUGUSTINE MANOR

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	363LG0600X	Gerontology Nurse Practitioner

General Provider Information

NPI Number	:	1033599105
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST AUGUSTINE MANOR

Provider Business Mailing Address
First Line	:	7801 DETROIT AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-2813
Country	:	US
Telephone Number	:	216-634-7400
Fax Number	:	216-634-7483

Provider Business Practice Location Address
First Line	:	7801 DETROIT AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-2813
Country	:	US
Telephone Number	:	216-634-7400
Fax Number	:	216-634-7483

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. FRANCIS S HUBA
Credential	:
Telephone Number	:	216-634-7555

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	06/04/2015

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Directions to “ST AUGUSTINE MANOR ” Practice Location

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