Provider Demographics
NPI:1043071558
Name:CLINICAL PRACTICE OF LECOM INSTITUTE FOR SUCCESSFUL LIVING
Entity Type:Organization
Organization Name:CLINICAL PRACTICE OF LECOM INSTITUTE FOR SUCCESSFUL LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:814-602-7783
Mailing Address - Street 1:5401 PEACH ST STE 3400
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2601
Mailing Address - Country:US
Mailing Address - Phone:814-868-2200
Mailing Address - Fax:
Practice Address - Street 1:9040 WATTSBURG RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-6024
Practice Address - Country:US
Practice Address - Phone:814-844-2858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLCREEK MANOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty