Healthcare Provider Details

I. General information

NPI: 1225874175
Provider Name (Legal Business Name): LAKE COUNTY FOOT & ANKLE ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8334 MENTOR AVE STE 100
MENTOR OH
44060-5757
US

IV. Provider business mailing address

8334 MENTOR AVE STE 100
MENTOR OH
44060-5757
US

V. Phone/Fax

Practice location:
  • Phone: 440-357-8418
  • Fax: 440-255-9400
Mailing address:
  • Phone: 440-357-8418
  • Fax: 440-255-9400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THERESA M FAUVER
Title or Position: MANAGER
Credential:
Phone: 440-357-8418