MEDICARE: MR. MARC WEATHERFORD LPN

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	164W00000X	Licensed Practical Nurse	PN117641	OH

General Provider Information

NPI Number	:	1467762138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARC WEATHERFORD LPN

Provider Business Mailing Address
First Line	:	1823 LEE RD APT 101
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-2152
Country	:	US
Telephone Number	:	216-371-9330
Fax Number	:

Provider Business Practice Location Address
First Line	:	1823 LEE RD APT 101
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-2152
Country	:	US
Telephone Number	:	216-371-9330
Fax Number	:

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

Provider Enumeration Date	:	10/15/2010
Last Update Date	:	10/15/2010

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