MEDICARE: DWAYNE EDWARD SEYMOUR

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	251E00000X	Home Health Agency	7611149	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7611149	OTHER	OH	OHIO DODD

General Provider Information

NPI Number	:	1053070151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DWAYNE EDWARD SEYMOUR

Provider Business Mailing Address
First Line	:	2364 ZIRCON ST NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44721-1741
Country	:	US
Telephone Number	:	330-685-2201
Fax Number	:

Provider Business Practice Location Address
First Line	:	2364 ZIRCON ST NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44721-1741
Country	:	US
Telephone Number	:	330-685-2201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2021
Last Update Date	:	12/16/2021

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