MEDICARE: CASSONDRA HARRIS

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	PN.130298	OH

General Provider Information

NPI Number	:	1932524576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASSONDRA HARRIS

Provider Business Mailing Address
First Line	:	17802 LAKE SHORE BLVD
Second Line	:	APT 4
City	:	EUCLID
State	:	OH
Zip	:	44119-1232
Country	:	US
Telephone Number	:	216-694-1163
Fax Number	:

Provider Business Practice Location Address
First Line	:	17802 LAKE SHORE BLVD
Second Line	:	APT 4
City	:	EUCLID
State	:	OH
Zip	:	44119-1232
Country	:	US
Telephone Number	:	216-694-1163
Fax Number	:

Authorized Official
Title or Position	:	LPN
Name	:	CASSONDRA HARRIS
Credential	:
Telephone Number	:	216-694-1163

Provider Enumeration Date	:	02/19/2014
Last Update Date	:	02/19/2014

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