Provider Demographics
NPI:1962477901
Name:LUCY IDOL CENTER, INC
Entity Type:Organization
Organization Name:LUCY IDOL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TAD
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-967-6724
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:435 NICHOLSON AVE
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-0162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 NICHOLSON RD
Practice Address - Street 2:
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-2536
Practice Address - Country:US
Practice Address - Phone:440-967-6724
Practice Address - Fax:440-967-4495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TM1800X, 171R00000X, 251C00000X, 261QA0600X, 343900000X, 3747A0650X, 3747P1801X, 374U00000X
OH0077261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No171R00000XOther Service ProvidersInterpreterGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty