Provider Demographics
NPI:1891237665
Name:LECOM SENIOR LIVING CENTER
Entity Type:Organization
Organization Name:LECOM SENIOR LIVING CENTER
Other - Org Name:MILLCREEK MANOR
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:TITZEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:8148-683-3812
Mailing Address - Street 1:5535 PEACH STREET
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-8528
Mailing Address - Country:US
Mailing Address - Phone:814-868-3820
Mailing Address - Fax:814-868-3887
Practice Address - Street 1:5535 PEACH STREET
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-8528
Practice Address - Country:US
Practice Address - Phone:814-868-3820
Practice Address - Fax:814-868-3887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLCREEK MANOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
806473133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty