Healthcare Provider Details

I. General information

NPI: 1356102859
Provider Name (Legal Business Name): CLINICAL PRACTICE OF LECOM INSTITUTE FOR SUCCESSFUL LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 W 24TH ST
ASHTABULA OH
44004-3423
US

IV. Provider business mailing address

5401 PEACH ST STE 3400
ERIE PA
16509-2601
US

V. Phone/Fax

Practice location:
  • Phone: 440-496-6500
  • Fax:
Mailing address:
  • Phone: 814-868-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES Y LIN
Title or Position: PRESIDENT
Credential: DO
Phone: 814-602-7783