Provider Demographics
NPI:1275787798
Name:LAKEWOOD SENIOR HEALTH CAMPUS
Entity Type:Organization
Organization Name:LAKEWOOD SENIOR HEALTH CAMPUS
Other - Org Name:LAKEWOOD - LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-327-9777
Mailing Address - Street 1:13900 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4624
Mailing Address - Country:US
Mailing Address - Phone:216-228-7650
Mailing Address - Fax:
Practice Address - Street 1:13900 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4624
Practice Address - Country:US
Practice Address - Phone:216-228-7650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:O'NEILL MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0336091291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory