Provider Demographics
NPI:1487151031
Name:THEOFYLAKTOS, NOULIS
Entity type:Individual
Prefix:MR
First Name:NOULIS
Middle Name:
Last Name:THEOFYLAKTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27181 GLOUCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-4450
Mailing Address - Country:US
Mailing Address - Phone:440-799-0539
Mailing Address - Fax:
Practice Address - Street 1:12395 MCCRACKEN RD STE A
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2946
Practice Address - Country:US
Practice Address - Phone:216-587-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator