Provider Demographics
NPI:1720537780
Name:INDIVIDUAL
Entity Type:Organization
Organization Name:INDIVIDUAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOME HEALTH AID
Authorized Official - Prefix:MISS
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MAYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-209-0732
Mailing Address - Street 1:1111 GONDER AVE SE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-3321
Mailing Address - Country:US
Mailing Address - Phone:330-209-0732
Mailing Address - Fax:
Practice Address - Street 1:1111 GONDER AVENUE SE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707
Practice Address - Country:US
Practice Address - Phone:330-209-0732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization