MEDICARE: MS. RANDALENE NICHOLE PORCH

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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1164111522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RANDALENE NICHOLE PORCH

Provider Business Mailing Address
First Line	:	3474 TULLAMORE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-3019
Country	:	US
Telephone Number	:	216-926-9243
Fax Number	:

Provider Business Practice Location Address
First Line	:	3474 TULLAMORE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-3019
Country	:	US
Telephone Number	:	216-926-9243
Fax Number	:

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

Provider Enumeration Date	:	05/02/2023
Last Update Date	:	05/02/2023

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