MEDICARE: SOUTHSIDE WELLNESS CENTER LTD

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	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1992049985	OTHER		NPI INDIVIDUAL

General Provider Information

NPI Number	:	1235718776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE WELLNESS CENTER LTD

Provider Business Mailing Address
First Line	:	7664 BROADVIEW RD
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44134-6746
Country	:	US
Telephone Number	:	440-840-7419
Fax Number	:	440-628-3503

Provider Business Practice Location Address
First Line	:	7664 BROADVIEW RD
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44134-6746
Country	:	US
Telephone Number	:	440-840-7419
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ CHIROPRACTOR
Name	:	SHOSHANA SEVEL LOERCH
Credential	:	DC
Telephone Number	:	440-840-7419

Provider Enumeration Date	:	04/02/2021
Last Update Date	:	04/30/2021

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