Provider Demographics
NPI:1861695710
Name:LAKE ATC
Entity type:Organization
Organization Name:LAKE ATC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE ANNE
Authorized Official - Middle Name:WALDMAN
Authorized Official - Last Name:LONSWAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:440-350-2547
Mailing Address - Street 1:270 E MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3856
Mailing Address - Country:US
Mailing Address - Phone:440-350-2547
Mailing Address - Fax:440-350-2940
Practice Address - Street 1:270 E MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3856
Practice Address - Country:US
Practice Address - Phone:440-350-2547
Practice Address - Fax:440-350-2940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1000277Medicaid