Provider Demographics
NPI:1730397282
Name:LAKE COUNTY FREE MEDICAL CLINIC
Entity type:Organization
Organization Name:LAKE COUNTY FREE MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNATONIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:FETZER
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:440-352-8686
Mailing Address - Street 1:54 S. STATE ST.
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077
Mailing Address - Country:US
Mailing Address - Phone:440-352-8686
Mailing Address - Fax:440-352-8107
Practice Address - Street 1:54 S STATE ST
Practice Address - Street 2:SUITE 302
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3445
Practice Address - Country:US
Practice Address - Phone:440-352-8686
Practice Address - Fax:440-352-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0716416Medicaid