Provider Demographics
NPI:1710536354
Name:DARE TO BE DIFFERENT, LLC
Entity Type:Organization
Organization Name:DARE TO BE DIFFERENT, LLC
Other - Org Name:DARE TO BE DIFFERENT LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PEER SUPPORTER
Authorized Official - Prefix:
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-313-9659
Mailing Address - Street 1:3568 BRINKMORE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1338
Mailing Address - Country:US
Mailing Address - Phone:501-313-9659
Mailing Address - Fax:
Practice Address - Street 1:3568 BRINKMORE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44121-1338
Practice Address - Country:US
Practice Address - Phone:501-313-9659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home