MEDICARE: LAKESH WYNETTE PORCH

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	1815334	OTHER	OH	DODD

General Provider Information

NPI Number	:	1376149658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKESH WYNETTE PORCH

Provider Business Mailing Address
First Line	:	1729 E 238TH ST
Second Line	:
City	:	EUCLID
State	:	OH
Zip	:	44117-1958
Country	:	US
Telephone Number	:	216-394-4502
Fax Number	:

Provider Business Practice Location Address
First Line	:	1729 E 238TH ST
Second Line	:
City	:	EUCLID
State	:	OH
Zip	:	44117-1958
Country	:	US
Telephone Number	:	216-394-4502
Fax Number	:

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

Provider Enumeration Date	:	12/10/2020
Last Update Date	:	12/10/2020

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Directions to “ LAKESH WYNETTE PORCH ” Practice Location

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