Provider Demographics
NPI:1932513694
Name:N/A
Entity Type:Organization
Organization Name:N/A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STNA
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-937-9110
Mailing Address - Street 1:8722 BECKMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-2337
Mailing Address - Country:US
Mailing Address - Phone:216-937-9110
Mailing Address - Fax:
Practice Address - Street 1:8722 BECKMAN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-2337
Practice Address - Country:US
Practice Address - Phone:216-937-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401616630214305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization