Healthcare Provider Details

I. General information

NPI: 1205896404
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7956 TYLER BLVD
MENTOR OH
44060-4806
US

IV. Provider business mailing address

PO BOX 781348
DETROIT MI
48278-1348
US

V. Phone/Fax

Practice location:
  • Phone: 440-255-6400
  • Fax: 440-255-3637
Mailing address:
  • Phone: 800-354-1985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT TRACZ
Title or Position: CFO
Credential:
Phone: 440-354-1952