MEDICARE: PROFOUND CARE,LLC.

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	163WH0200X	Home Health Registered Nurse	RN. 311778	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2624066	OTHER	OH	CARE STAR IPN

General Provider Information

NPI Number	:	1457474876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFOUND CARE,LLC.

Provider Business Mailing Address
First Line	:	5289 EISENHOWER ROAD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-5016
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5289 EISENHOWER RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-5016
Country	:	US
Telephone Number	:	614-433-0064
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. EDWARD RAYMOND LEAKE
Credential	:	BSN,RN,MS
Telephone Number	:	614-433-0064

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	04/23/2008

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Directions to “PROFOUND CARE,LLC. ” Practice Location

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