MEDICARE: KOINONIA COMMUNITY SERVICES 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	315P00000X	Intellectual Disabilities Intermediate Care Facility

General Provider Information

NPI Number	:	1457994840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOINONIA COMMUNITY SERVICES LLC

Provider Business Mailing Address
First Line	:	6161 OAK TREE BLVD STE 400
Second Line	:
City	:	INDEPENDENCE
State	:	OH
Zip	:	44131-2581
Country	:	US
Telephone Number	:	216-588-8777
Fax Number	:	216-588-5670

Provider Business Practice Location Address
First Line	:	2980 VAN AKEN BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-2862
Country	:	US
Telephone Number	:	216-561-7415
Fax Number	:	216-561-0367

Authorized Official
Title or Position	:	DIRECTOR OF ICF
Name	:	MARILINA WORKMAN
Credential	:
Telephone Number	:	216-588-8777

Provider Enumeration Date	:	10/18/2019
Last Update Date	:	10/18/2019

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