MEDICARE: LAKE ERIE PREPARATORY SCHOOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1407282684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE ERIE PREPARATORY SCHOOL

Provider Business Mailing Address
First Line	:	219 E MAPLE ST
Second Line	:	SUITE #202
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-2586
Country	:	US
Telephone Number	:	330-515-0572
Fax Number	:	330-409-0270

Provider Business Practice Location Address
First Line	:	14405 SAINT CLAIR AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-3433
Country	:	US
Telephone Number	:	330-515-0572
Fax Number	:	330-409-0270

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. C. DAVID MASSA
Credential	:	CPA
Telephone Number	:	330-515-0572

Provider Enumeration Date	:	09/19/2013
Last Update Date	:	09/26/2013

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