MEDICARE: DARE TO BE DIFFERENT, LLC

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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1710536354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DARE TO BE DIFFERENT, LLC

Provider Business Mailing Address
First Line	:	3568 BRINKMORE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1338
Country	:	US
Telephone Number	:	501-313-9659
Fax Number	:

Provider Business Practice Location Address
First Line	:	3568 BRINKMORE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1338
Country	:	US
Telephone Number	:	501-313-9659
Fax Number	:

Authorized Official
Title or Position	:	PEER SUPPORTER
Name	:	BERNICE PETTY
Credential	:
Telephone Number	:	501-313-9659

Provider Enumeration Date	:	09/06/2019
Last Update Date	:	12/12/2022

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Directions to “DARE TO BE DIFFERENT, LLC ” Practice Location

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