MEDICARE: PROGRESSIVE GREEN MEADOWS 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	291U00000X	Clinical Medical Laboratory	36D0983541	OH

General Provider Information

NPI Number	:	1235390006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRESSIVE GREEN MEADOWS LLC

Provider Business Mailing Address
First Line	:	7770 COLUMBUS RD
Second Line	:
City	:	LOUISVILLE
State	:	OH
Zip	:	44641-9773
Country	:	US
Telephone Number	:	330-875-1456
Fax Number	:

Provider Business Practice Location Address
First Line	:	7770 COLUMBUS RD
Second Line	:
City	:	LOUISVILLE
State	:	OH
Zip	:	44641-9773
Country	:	US
Telephone Number	:	330-875-1456
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. SHAUL FLANK
Credential	:
Telephone Number	:	216-661-6800

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	06/24/2008

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