MEDICARE: TORE'AN DE'VAE NELSON

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	251E00000X	Home Health Agency	401990680717	OH

General Provider Information

NPI Number	:	1942787155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TORE'AN DE'VAE NELSON

Provider Business Mailing Address
First Line	:	1405 PARKMAN RD NW
Second Line	:
City	:	WARREN
State	:	OH
Zip	:	44485-2156
Country	:	US
Telephone Number	:	330-623-1161
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 PARKMAN RD NW
Second Line	:
City	:	WARREN
State	:	OH
Zip	:	44485-2156
Country	:	US
Telephone Number	:	330-623-1161
Fax Number	:

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

Provider Enumeration Date	:	07/20/2018
Last Update Date	:	07/20/2018

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