Healthcare Provider Details

I. General information

NPI: 1891237665
Provider Name (Legal Business Name): LECOM SENIOR LIVING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 PEACH STREET
ERIE PA
16509-8528
US

IV. Provider business mailing address

5535 PEACH STREET
ERIE PA
16509-8528
US

V. Phone/Fax

Practice location:
  • Phone: 814-868-3820
  • Fax: 814-868-3887
Mailing address:
  • Phone: 814-868-3820
  • Fax: 814-868-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number806473
License Number StateNULL

VIII. Authorized Official

Name: DR. MELANIE RAE TITZEL
Title or Position: DIRECTOR OF OPERATIONS
Credential: PH.D.
Phone: 81486833812