Provider Demographics
NPI:1134489677
Name:LAKE HEALTH
Entity Type:Organization
Organization Name:LAKE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTORLAKEHEALTHWELLNESSINSTITUTE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:JODY
Authorized Official - Last Name:MINJARES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD
Authorized Official - Phone:440-350-4512
Mailing Address - Street 1:7580 AUBURN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9617
Mailing Address - Country:US
Mailing Address - Phone:440-375-8153
Mailing Address - Fax:440-375-8154
Practice Address - Street 1:7580 AUBURN RD STE 201
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-9617
Practice Address - Country:US
Practice Address - Phone:440-375-8153
Practice Address - Fax:440-375-8154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6868133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty