MEDICARE: RESILIENCE ANTI-AGING & INTERNAL MEDICINE WELLNESS CLINIC 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1831576446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESILIENCE ANTI-AGING & INTERNAL MEDICINE WELLNESS CLINIC INC

Provider Business Mailing Address
First Line	:	25701 N LAKELAND BLVD
Second Line	:	SUITE 300
City	:	EUCLID
State	:	OH
Zip	:	44132-2450
Country	:	US
Telephone Number	:	216-261-6398
Fax Number	:	440-525-5564

Provider Business Practice Location Address
First Line	:	25701 N LAKELAND BLVD
Second Line	:	SUITE 300
City	:	EUCLID
State	:	OH
Zip	:	44132-2450
Country	:	US
Telephone Number	:	216-261-6398
Fax Number	:	440-525-5564

Authorized Official
Title or Position	:	V.P.
Name	:	MR. DONAVON HUFF
Credential	:	MASTER TRAINER
Telephone Number	:	216-261-3698

Provider Enumeration Date	:	05/04/2015
Last Update Date	:	04/25/2016

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