Provider Demographics
NPI:1144694621
Name:LIFECARE FAMILY HEALTH AND DENTAL CENTER, INC.
Entity type:Organization
Organization Name:LIFECARE FAMILY HEALTH AND DENTAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:MCPEEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:234-521-7213
Mailing Address - Street 1:2725 LINCOLN ST E
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-2769
Mailing Address - Country:US
Mailing Address - Phone:330-454-2000
Mailing Address - Fax:
Practice Address - Street 1:820 AMHERST RD NE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-8525
Practice Address - Country:US
Practice Address - Phone:303-454-2000
Practice Address - Fax:330-454-6184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0171070Medicaid