MEDICARE: LUCAS COUNTY COMMUNITY PREVENTION PARTNERSHIP

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1689761298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCAS COUNTY COMMUNITY PREVENTION PARTNERSHIP

Provider Business Mailing Address
First Line	:	5902 SOUTHWYCK BLVD STE 100
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-1523
Country	:	US
Telephone Number	:	419-866-3611
Fax Number	:	419-866-3613

Provider Business Practice Location Address
First Line	:	5902 SOUTHWYCK BLVD STE 100
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-1523
Country	:	US
Telephone Number	:	419-866-3611
Fax Number	:	419-866-3613

Authorized Official
Title or Position	:	CEO
Name	:	MR. DEACON D DZIERZAWSKI
Credential	:
Telephone Number	:	419-866-3611

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	08/22/2020

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