Provider Demographics
NPI:1417405341
Name:YOUR SECOND FAMILY
Entity Type:Organization
Organization Name:YOUR SECOND FAMILY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-385-5362
Mailing Address - Street 1:4901 MEMPHIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44144-1943
Mailing Address - Country:US
Mailing Address - Phone:216-820-0718
Mailing Address - Fax:
Practice Address - Street 1:4901 MEMPHIS AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44144-1943
Practice Address - Country:US
Practice Address - Phone:216-820-0718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0146044261QA0600X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0146044Medicaid