MEDICARE: CARESTAR (ODJFS)

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	PN142508	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649573478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARESTAR (ODJFS)

Provider Business Mailing Address
First Line	:	3263 E 123RD ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-3849
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3263 E 123RD ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-3849
Country	:	US
Telephone Number	:	216-217-0463
Fax Number	:

Authorized Official
Title or Position	:	LPN
Name	:	LACINDA JENKINS
Credential	:
Telephone Number	:	216-217-0463

Provider Enumeration Date	:	12/17/2010
Last Update Date	:	12/17/2010

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Directions to “CARESTAR (ODJFS) ” Practice Location

Language	Start Address	Practice Location

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