Provider Demographics
NPI:1275107880
Name:LAKE COUNTY BOARD DD
Entity Type:Organization
Organization Name:LAKE COUNTY BOARD DD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:EFRIEDE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-350-5100
Mailing Address - Street 1:8121 DEEPWOOD BOULEVARD
Mailing Address - Street 2:BUILDING B
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-7703
Mailing Address - Country:US
Mailing Address - Phone:440-350-5100
Mailing Address - Fax:440-350-5290
Practice Address - Street 1:8121 DEEPWOOD BOULEVARD
Practice Address - Street 2:BUILDING B
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-7703
Practice Address - Country:US
Practice Address - Phone:440-350-5100
Practice Address - Fax:440-350-5290
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE COUNTY BOARD DD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities