Provider Demographics
NPI:1750712956
Name:NA
Entity type:Organization
Organization Name:NA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STNA
Authorized Official - Prefix:
Authorized Official - First Name:TASHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-213-8084
Mailing Address - Street 1:7629 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-5927
Mailing Address - Country:US
Mailing Address - Phone:216-213-8084
Mailing Address - Fax:
Practice Address - Street 1:7629 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-5927
Practice Address - Country:US
Practice Address - Phone:216-213-8084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400360060504311500000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)