MEDICARE: EASTLAND PREPARATORY ACADEMY

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	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1407400211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTLAND PREPARATORY ACADEMY

Provider Business Mailing Address
First Line	:	219 E MAPLE ST STE 202
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-2586
Country	:	US
Telephone Number	:	330-515-0572
Fax Number	:

Provider Business Practice Location Address
First Line	:	2741 S HAMILTON RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4904
Country	:	US
Telephone Number	:	330-515-0572
Fax Number	:

Authorized Official
Title or Position	:	FISCAL OFFICER
Name	:	DAVE MASSA
Credential	:
Telephone Number	:	330-515-0572

Provider Enumeration Date	:	07/30/2019
Last Update Date	:	07/30/2019

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