MEDICARE: OLD SCHOOL LLC

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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	101YA0400X	OH

General Provider Information

NPI Number	:	1215329909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD SCHOOL LLC

Provider Business Mailing Address
First Line	:	2109 WOOSTER RD
Second Line	:
City	:	ROCKY RIVER
State	:	OH
Zip	:	44116-2674
Country	:	US
Telephone Number	:	216-407-0437
Fax Number	:	216-862-5143

Provider Business Practice Location Address
First Line	:	17400 NORTHWOOD AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-2210
Country	:	US
Telephone Number	:	216-403-8640
Fax Number	:	216-862-5143

Authorized Official
Title or Position	:	DIRECTOR/OWNER
Name	:	MR. JOHN J. SMITH
Credential	:
Telephone Number	:	216-407-0437

Provider Enumeration Date	:	03/04/2015
Last Update Date	:	03/04/2015

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