Healthcare Provider Details

I. General information

NPI: 1154048320
Provider Name (Legal Business Name): LAKESHORE POND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1757 WICKFORD RD
CLEVELAND OH
44112-1207
US

IV. Provider business mailing address

25000 EUCLID AVE STE 401
EUCLID OH
44117-2645
US

V. Phone/Fax

Practice location:
  • Phone: 216-245-8550
  • Fax:
Mailing address:
  • Phone: 216-245-8550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHASHONNA DUCKWORTH
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 216-245-8550