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General NPI Number Information
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NPI Number | 1114057171
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Entity Type | Organization
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Legal Business Name | LAKE COUNTY FAMILY PRACTICE, LLC
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 07/28/2008
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Provider Practice Location Address
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Address Line | 9500 MENTOR AVENUE SUITE 100
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City | MENTOR
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State | OH
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Zip | 44060
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Country | US
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Telephone | 440-352-4880
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Fax | 440-352-3629
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Provider Business Mailing Address
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Address Line | PO BOX 75358
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City | CLEVELAND
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State | OH
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Zip | 44101-2199
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Country | US
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Telephone | 440-352-4880
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Fax | 440-352-3629
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. EILEEN SRAJ
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Credential |
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Telephone | 440-352-4880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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