MEDICARE: CHARLES MACK LEE STNA

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	374U00000X	Home Health Aide	400327400204	OH

General Provider Information

NPI Number	:	1629115779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES MACK LEE STNA

Provider Business Mailing Address
First Line	:	PO BOX 19483
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-0483
Country	:	US
Telephone Number	:	216-832-7732
Fax Number	:

Provider Business Practice Location Address
First Line	:	3919 E 147TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-1082
Country	:	US
Telephone Number	:	216-832-7732
Fax Number	:

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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