Provider Demographics
NPI:1972106862
Name:MYADZE, IVEREN
Entity Type:Individual
Prefix:
First Name:IVEREN
Middle Name:
Last Name:MYADZE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24423
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-0423
Mailing Address - Country:US
Mailing Address - Phone:937-607-8845
Mailing Address - Fax:
Practice Address - Street 1:7300 CHARLESWORTH DR
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-3256
Practice Address - Country:US
Practice Address - Phone:937-607-8845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2414686Medicaid