MEDICARE: ROSHAWN K SAMPLE

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	385H00000X	Respite Care

General Provider Information

NPI Number	:	1396558599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSHAWN K SAMPLE

Provider Business Mailing Address
First Line	:	25030 TRYON RD
Second Line	:
City	:	OAKWOOD VILLAGE
State	:	OH
Zip	:	44146-6049
Country	:	US
Telephone Number	:	216-410-5342
Fax Number	:

Provider Business Practice Location Address
First Line	:	4127 E 131ST ST STE 200
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44105-5563
Country	:	US
Telephone Number	:	216-410-5342
Fax Number	:

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

Provider Enumeration Date	:	01/30/2025
Last Update Date	:	01/30/2025

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Directions to “ ROSHAWN K SAMPLE ” Practice Location

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