Healthcare Provider Details

I. General information

NPI: 1114057171
Provider Name (Legal Business Name): LAKE COUNTY FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 MENTOR AVENUE SUITE 100
MENTOR OH
44060
US

IV. Provider business mailing address

PO BOX 75358
CLEVELAND OH
44101-2199
US

V. Phone/Fax

Practice location:
  • Phone: 440-352-4880
  • Fax: 440-352-3629
Mailing address:
  • Phone: 440-352-4880
  • Fax: 440-352-3629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. EILEEN SRAJ
Title or Position: OFFICE MANAGER
Credential:
Phone: 440-352-4880