MEDICARE: EYE FOR CHANGE YOUTH & FAMILY SERVICES, INC.

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1740724624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE FOR CHANGE YOUTH & FAMILY SERVICES, INC.

Provider Business Mailing Address
First Line	:	3100 E 45TH ST
Second Line	:	SUITE 314
City	:	CLEVELAND
State	:	OH
Zip	:	44127-1088
Country	:	US
Telephone Number	:	216-441-9622
Fax Number	:	888-460-7417

Provider Business Practice Location Address
First Line	:	3100 E 45TH ST
Second Line	:	SUITE 314
City	:	CLEVELAND
State	:	OH
Zip	:	44127-1088
Country	:	US
Telephone Number	:	216-441-9622
Fax Number	:	888-460-7417

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ALFONZO D BAILEY
Credential	:	MPA
Telephone Number	:	216-441-9622

Provider Enumeration Date	:	12/12/2016
Last Update Date	:	12/12/2016

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