Provider Demographics
NPI:1447201470
Name:WAKEMAN AREA FAMILY CARE CENTER
Entity Type:Organization
Organization Name:WAKEMAN AREA FAMILY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:TANIGAWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-839-2226
Mailing Address - Street 1:24 HYDE ST
Mailing Address - Street 2:
Mailing Address - City:WAKEMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44889-9301
Mailing Address - Country:US
Mailing Address - Phone:440-839-2226
Mailing Address - Fax:440-839-1339
Practice Address - Street 1:24 HYDE ST
Practice Address - Street 2:
Practice Address - City:WAKEMAN
Practice Address - State:OH
Practice Address - Zip Code:44889-9301
Practice Address - Country:US
Practice Address - Phone:440-839-2226
Practice Address - Fax:440-839-1339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062083207Q00000X
OH50000956363A00000X
OHNP08465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2158481Medicaid
OH2158481Medicaid