=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518352939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2015
-----------------------------------------------------
Last Update Date | 05/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 W GRANDVIEW BLVD
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16509-1029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-868-1001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1858 W GRANDVIEW BLVD
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16509-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP FISCAL AFFAIRS/CFO
-----------------------------------------------------
Name | STEVEN GREGORY INMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-868-8258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------