Healthcare Provider Details

I. General information

NPI: 1023564143
Provider Name (Legal Business Name): LORAIN COUNTY HEALTH & DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 PARK SQUARE DR.
LORAIN OH
44053-4153
US

IV. Provider business mailing address

1205 BROADWAY AVE
LORAIN OH
44052-3409
US

V. Phone/Fax

Practice location:
  • Phone: 440-240-1655
  • Fax: 440-240-1655
Mailing address:
  • Phone: 440-240-1655
  • Fax: 440-240-1663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LISA M HEMKER
Title or Position: CREDENTIALINGLORAINHEALTH-DENTISTRY
Credential: CFO
Phone: 440-240-1655