MEDICARE: CLINICAL PRACTICE OF LECOM INSTITUTE FOR SUCCESSFUL LIVING

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	213E00000X	Podiatrist
2	363L00000X	Nurse Practitioner
3	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1689489718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICAL PRACTICE OF LECOM INSTITUTE FOR SUCCESSFUL LIVING

Provider Business Mailing Address
First Line	:	5535 PEACH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16509-2603
Country	:	US
Telephone Number	:	814-844-2858
Fax Number	:

Provider Business Practice Location Address
First Line	:	16954 CONNEAUT LAKE RD
Second Line	:
City	:	MEADVILLE
State	:	PA
Zip	:	16335-3738
Country	:	US
Telephone Number	:	814-844-2858
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES LIN
Credential	:
Telephone Number	:	814-602-7783

Provider Enumeration Date	:	02/07/2025
Last Update Date	:	10/13/2025

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