Provider Demographics
NPI:1043369481
Name:LAKESHORE COMMUNITY SERVICES, INC.
Entity Type:Organization
Organization Name:LAKESHORE COMMUNITY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-456-9962
Mailing Address - Street 1:1350 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-1402
Mailing Address - Country:US
Mailing Address - Phone:814-456-9962
Mailing Address - Fax:814-456-0595
Practice Address - Street 1:1350 W 26TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-1402
Practice Address - Country:US
Practice Address - Phone:814-456-9962
Practice Address - Fax:814-456-0595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000010470079Medicaid