Provider Demographics
NPI:1598826216
Name:COUNTY OF LAKE COURT HOUSE
Entity Type:Organization
Organization Name:COUNTY OF LAKE COURT HOUSE
Other - Org Name:LAKE COUNTY GENERAL HEALTH DISTRICT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH COMISSIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RD/RDN, LD, MPH
Authorized Official - Phone:440-350-2554
Mailing Address - Street 1:5966 HEISLEY RD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-1886
Mailing Address - Country:US
Mailing Address - Phone:440-350-2554
Mailing Address - Fax:440-350-2956
Practice Address - Street 1:5966 HEISLEY RD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-1886
Practice Address - Country:US
Practice Address - Phone:440-350-2554
Practice Address - Fax:440-350-2956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0567480Medicaid
OH0567480Medicaid
OH600000984Medicare ID - Type UnspecifiedRAILROAD MEDICARE PART B