Healthcare Provider Details

I. General information

NPI: 1326022625
Provider Name (Legal Business Name): MANOR AVENUE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 E MANOR AVE
STRUTHERS OH
44471-1545
US

IV. Provider business mailing address

296 E MANOR AVE
STRUTHERS OH
44471-1545
US

V. Phone/Fax

Practice location:
  • Phone: 330-755-3233
  • Fax: 330-755-4511
Mailing address:
  • Phone: 330-755-3233
  • Fax: 330-755-4511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW J LOCKSHAW III
Title or Position: DO
Credential: DO
Phone: 330-755-3233