MEDICARE: MR. JESSE LEON DISMON SR.

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	096091	OH

General Provider Information

NPI Number	:	1710252358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSE LEON DISMON SR.

Provider Business Mailing Address
First Line	:	1718 GLENMONT RD # 1
Second Line	:
City	:	CLEVELAND HTS
State	:	OH
Zip	:	44118-1135
Country	:	US
Telephone Number	:	216-548-7140
Fax Number	:

Provider Business Practice Location Address
First Line	:	1718 GLENMONT RD # 1
Second Line	:
City	:	CLEVELAND HTS
State	:	OH
Zip	:	44118-1135
Country	:	US
Telephone Number	:	216-548-7140
Fax Number	:

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

Provider Enumeration Date	:	03/15/2012
Last Update Date	:	06/13/2012

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