Provider Demographics
NPI:1174935324
Name:LOST CREEK HOLDING, LLC
Entity type:Organization
Organization Name:LOST CREEK HOLDING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-230-5446
Mailing Address - Street 1:2750 N THAYER RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-8796
Mailing Address - Country:US
Mailing Address - Phone:419-230-5446
Mailing Address - Fax:
Practice Address - Street 1:2750 N THAYER RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-8796
Practice Address - Country:US
Practice Address - Phone:419-230-5446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH31-5060261QD0000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental