Healthcare Provider Details

I. General information

NPI: 1083897136
Provider Name (Legal Business Name): LAKE ANNA PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 STAR LN
WADSWORTH OH
44281-9546
US

IV. Provider business mailing address

PO BOX 43
CUYAHOGA FALLS OH
44222-0043
US

V. Phone/Fax

Practice location:
  • Phone: 216-420-9403
  • Fax: 216-420-9354
Mailing address:
  • Phone: 216-420-9403
  • Fax: 216-420-9354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35049143
License Number StateOH

VIII. Authorized Official

Name: THOMAS S. LEHNER
Title or Position: OWNER
Credential: MD
Phone: 216-420-9403