Provider Demographics
NPI:1114057171
Name:LAKE COUNTY FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:LAKE COUNTY FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SRAJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-352-4880
Mailing Address - Street 1:PO BOX 75358
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-2199
Mailing Address - Country:US
Mailing Address - Phone:440-352-4880
Mailing Address - Fax:440-352-3629
Practice Address - Street 1:9500 MENTOR AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-352-4880
Practice Address - Fax:440-352-3629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0588430Medicaid
OH0588430Medicaid
OH0588430Medicaid