Healthcare Provider Details

I. General information

NPI: 1821905720
Provider Name (Legal Business Name): LAKE ERIE INTEGRATIVE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 STATE ST
CONNEAUT OH
44030-2670
US

IV. Provider business mailing address

268 STATE ST
CONNEAUT OH
44030-2670
US

V. Phone/Fax

Practice location:
  • Phone: 440-209-2916
  • Fax:
Mailing address:
  • Phone: 440-209-2916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: TATYANA N KUVSHINIKOV
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 440-209-2916