MEDICARE: A DIFFERENT EDGE RESIDENTIAL SERVICES, LLP

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1033833934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A DIFFERENT EDGE RESIDENTIAL SERVICES, LLP

Provider Business Mailing Address
First Line	:	33140 AURORA RD STE 3
Second Line	:
City	:	SOLON
State	:	OH
Zip	:	44139-3650
Country	:	US
Telephone Number	:	216-210-2865
Fax Number	:

Provider Business Practice Location Address
First Line	:	33140 AURORA RD STE 3
Second Line	:
City	:	SOLON
State	:	OH
Zip	:	44139-3650
Country	:	US
Telephone Number	:	216-210-2865
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	SHAMARAH THOMAS-HUTCHINS
Credential	:	PH.D
Telephone Number	:	216-210-2865

Provider Enumeration Date	:	10/04/2022
Last Update Date	:	10/04/2022

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