Provider Demographics
NPI:1700109691
Name:LAKE OHIO HOME HEALTH
Entity Type:Organization
Organization Name:LAKE OHIO HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:GLORIA
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:216-235-6479
Mailing Address - Street 1:2490 LEE BLVD STE 217
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1269
Mailing Address - Country:US
Mailing Address - Phone:216-235-6479
Mailing Address - Fax:
Practice Address - Street 1:2490 LEE BLVD STE 217
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1269
Practice Address - Country:US
Practice Address - Phone:216-235-6479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH229294251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1184819021Medicaid