MEDICARE: DWAYNE JOHNSON

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1225872542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DWAYNE JOHNSON

Provider Business Mailing Address
First Line	:	14001 SCIOTO AVE
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-3738
Country	:	US
Telephone Number	:	216-421-4427
Fax Number	:

Provider Business Practice Location Address
First Line	:	14001 SCIOTO AVE
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-3738
Country	:	US
Telephone Number	:	216-421-4427
Fax Number	:

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

Provider Enumeration Date	:	06/21/2024
Last Update Date	:	08/20/2024

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Directions to “ DWAYNE JOHNSON ” Practice Location

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