NPIMap

Organization Active NPI

Clinical Practice of Lecom Institute for Successful Living

  • Rural Health Clinic/Center
  • Erie, PA
National Provider Identifier
1043071558
Registry record updated Jan 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CLINICAL PRACTICE OF LECOM INSTITUTE FOR SUCCESSFUL LIVING
Practice address
9040 Wattsburg Rd
Erie, PA 16509-6024
Phone
(814) 844-2858
NPI assigned
Jan 22, 2024
Organization subpart
Yes
Parent organization
MILLCREEK MANORAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 22, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
James Y Lin, DONPI 1164599155
Title
President
Phone
(814) 602-7783

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

9040 Wattsburg Rd
Erie, PA 16509-6024

Mailing address

5401 Peach St Ste 3400
Erie, PA 16509-2601
Phone (814) 868-2200

Other names 1

  • Rural Health Clinic of Wattsburg Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20240402000412 PA Part B Supplier - Clinic/Group Practice 2466890033 Receives reassigned benefits from 22 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Erie, PA; Meadville, PA
O20240524002878 PA Part A Provider - Rural Health Clinic 2466890033 Practice locations: Erie, PA

Rural health clinic certification: CCN 393929

Legal name
CLINICAL PRACTICE OF LECOM INSTITUTE FOR SUCCESSFUL LIVING
Doing business as
RURAL HEALTH CLINIC OF WATTSBURG
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 28, 2024
Last certification
Jun 28, 2024
Ownership / control type
2B
Organization structure
OtherNon-profit
Incorporated
Oct 1, 1989 in PA
Enrollment address
9040 Wattsburg Rd
Erie, PA 16509-6024

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
39D2306207Rural Health Clinic of Wattsburg9040 Wattsburg Rd, Erie, PA 16509Certificate of waiverJun 12, 2028

National Provider Directory

National Provider Directory
Tax ID family
Clinical Practice of Lecom Institute for Successful Living5 organizations share this tax ID, including this one
Part of
Millcreek Manor

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
John M Ferretti Individual Corporate OfficerPresident Jan 7, 2008
Millcreek Manor Organization, Erie, PA Non-profit 5% Or Greater Direct Ownership Interest Aug 24, 2023 100%
Silvia M Ferretti Individual Corporate OfficerVice President Jan 7, 2008
Joseph Kelly Individual Corporate DirectorBoard Member Jan 1, 2021
James Yi Lin Individual Corporate DirectorBoard Member Mar 29, 2024
W-2 Managing EmployeeAd;MD; Jan 7, 2008
Joyce Savocchio Individual Corporate Director Jan 7, 2008
Esther Fucci Individual Corporate DirectorBoard Member Jan 7, 2008
Mary L Eckert Individual Corporate DirectorSecretary Jan 7, 2008
Vincent S Fierro Individual Corporate DirectorBoard Member Jan 7, 2008

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 5

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1705881600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705881600000",
    "number": "1043071558",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5401 PEACH ST STE 3400",
            "city": "ERIE",
            "state": "PA",
            "postal_code": "165092601",
            "telephone_number": "814-868-2200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9040 WATTSBURG RD",
            "city": "ERIE",
            "state": "PA",
            "postal_code": "165096024",
            "telephone_number": "814-844-2858"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLINICAL PRACTICE OF LECOM INSTITUTE FOR SUCCESSFUL LIVING",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MILLCREEK MANOR",
        "enumeration_date": "2024-01-22",
        "last_updated": "2024-01-22",
        "certification_date": "2024-01-22",
        "status": "A",
        "authorized_official_last_name": "LIN",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "Y",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "814-602-7783",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Rural Health Clinic of Wattsburg",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Erie, PA

Sources for this page

Verify at the official NPI Registry.