Provider Demographics
NPI:1780613851
Name:LAKE ORTHOPAEDIC ASSOCIATES, INC.
Entity type:Organization
Organization Name:LAKE ORTHOPAEDIC ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAUREEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PELLETIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-352-1711
Mailing Address - Street 1:9500 MENTOR AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8713
Mailing Address - Country:US
Mailing Address - Phone:440-352-1711
Mailing Address - Fax:440-352-7562
Practice Address - Street 1:9500 MENTOR AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8713
Practice Address - Country:US
Practice Address - Phone:440-352-1711
Practice Address - Fax:440-352-7562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0975066Medicaid
OHDE9928642Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER