MEDICARE: EAST CLEVELAND OH CAREGIVING 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	261QM1300X	Multi-Specialty Clinic/Center
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1841892569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST CLEVELAND OH CAREGIVING LLC

Provider Business Mailing Address
First Line	:	209 S 28TH ST
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-7415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11201 SHAKER BLVD STE 202
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-3873
Country	:	US
Telephone Number	:	216-290-3520
Fax Number	:

Authorized Official
Title or Position	:	VP BUSINESS DEVELOPMENT
Name	:	AVERY LAIN
Credential	:
Telephone Number	:	817-991-7836

Provider Enumeration Date	:	11/09/2020
Last Update Date	:	12/21/2021

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