Organization
UPMC COMMUNITY MEDICINE
Active
Parent organization
MEDVANTX, INC
Other names
Lakeside Family Medicine Conneaut Lake
Organization subpart
Yes
Provider details
NPI number
Legal business name
MEDVANTX, INC
Authorized official
KENNY HEINE (VP OF OPERATIONS)
(858) 964-1506
Entity
Organization
Contact information
Practice address
11065 STATE HIGHWAY 18, SUITE 1, CONNEAUT LAKE, PA 16316-3569
(814) 382-6550
Mailing address
5626 OBERLIN DR, SUITE 110, SAN DIEGO, CA 92121-1705
Taxonomy
Speciality
Code
Description
License number
State
332900000X
Non-Pharmacy Dispensing Site
Primary
OS012755
PA
Other
Enumeration date
08/21/2014
Last updated
08/21/2014
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