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NPI Code Detail

MEDICARE: LACEY FAIR-MCCULLOUGH

MEDICARE: LACEY FAIR-MCCULLOUGH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1171M00000XCase Manager/Care CoordinatorOH

General Provider Information

NPI Number : 1356273106
Entity Type Code : Individual
Provider Name (Legal Business Name) : LACEY FAIR-MCCULLOUGH
Provider Business Mailing Address
First Line : 12041 RAVENNA RD
Second Line :
City : CHARDON
State : OH
Zip : 44024-7008
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 12041 RAVENNA RD
Second Line :
City : CHARDON
State : OH
Zip : 44024-7008
Country : US
Telephone Number : 440-286-7154
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/03/2026
Last Update Date : 06/03/2026

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Directions to “ LACEY FAIR-MCCULLOUGH ” Practice Location

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