MEDICARE: SARETTA LANIECE GORDON-EDENBURGH

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	171W00000X	Contractor	SM696161	OH

General Provider Information

NPI Number	:	1619712825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARETTA LANIECE GORDON-EDENBURGH

Provider Business Mailing Address
First Line	:	1405 VILLA DR
Second Line	:
City	:	SOUTH EUCLID
State	:	OH
Zip	:	44121-2903
Country	:	US
Telephone Number	:	216-716-0242
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 VILLA DR
Second Line	:
City	:	SOUTH EUCLID
State	:	OH
Zip	:	44121-2903
Country	:	US
Telephone Number	:	216-716-0242
Fax Number	:

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

Provider Enumeration Date	:	06/28/2024
Last Update Date	:	06/28/2024

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Directions to “ SARETTA LANIECE GORDON-EDENBURGH ” Practice Location

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