MEDICARE: ANTONIO LEO BENNETT

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	3747P1801X	Personal Care Attendant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376139113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONIO LEO BENNETT

Provider Business Mailing Address
First Line	:	12609 SIGNET AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-3168
Country	:	US
Telephone Number	:	216-210-0227
Fax Number	:

Provider Business Practice Location Address
First Line	:	12609 SIGNET AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-3168
Country	:	US
Telephone Number	:	216-210-0227
Fax Number	:

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

Provider Enumeration Date	:	12/16/2020
Last Update Date	:	12/16/2020

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Directions to “ ANTONIO LEO BENNETT ” Practice Location

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