Provider Demographics
NPI:1467048470
Name:IERACI, ANTHONY F
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:F
Last Name:IERACI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 STARRS CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3680 STARRS CENTRE DR
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9514
Practice Address - Country:US
Practice Address - Phone:330-967-4056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5005902320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities