Provider Demographics
NPI:1326022625
Name:MANOR AVENUE CLINIC INC
Entity Type:Organization
Organization Name:MANOR AVENUE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOCKSHAW
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:330-755-3233
Mailing Address - Street 1:296 E MANOR AVE
Mailing Address - Street 2:
Mailing Address - City:STRUTHERS
Mailing Address - State:OH
Mailing Address - Zip Code:44471-1545
Mailing Address - Country:US
Mailing Address - Phone:330-755-3233
Mailing Address - Fax:330-755-4511
Practice Address - Street 1:296 E MANOR AVE
Practice Address - Street 2:
Practice Address - City:STRUTHERS
Practice Address - State:OH
Practice Address - Zip Code:44471-1545
Practice Address - Country:US
Practice Address - Phone:330-755-3233
Practice Address - Fax:330-755-4511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0795564Medicaid
OH0795564Medicaid
C02951Medicare UPIN