MEDICARE: EVAN LASHON MCDUFFIE

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1750093449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVAN LASHON MCDUFFIE

Provider Business Mailing Address
First Line	:	16402 ARCADE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-1610
Country	:	US
Telephone Number	:	216-860-8887
Fax Number	:

Provider Business Practice Location Address
First Line	:	16402 ARCADE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-1610
Country	:	US
Telephone Number	:	216-860-8887
Fax Number	:

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

Provider Enumeration Date	:	12/14/2022
Last Update Date	:	12/14/2022

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