MEDICARE: CHARLES A CRADDOCK III

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		OH

General Provider Information

NPI Number	:	1962218586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES A CRADDOCK III

Provider Business Mailing Address
First Line	:	5135 E 112TH ST
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44125-2729
Country	:	US
Telephone Number	:	216-278-4717
Fax Number	:

Provider Business Practice Location Address
First Line	:	5135 E 112TH ST
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44125-2729
Country	:	US
Telephone Number	:	216-278-4717
Fax Number	:

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

Provider Enumeration Date	:	12/09/2024
Last Update Date	:	12/09/2024

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Directions to “ CHARLES A CRADDOCK III ” Practice Location

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