NPIMap

Organization Active NPI

Lifecare Family Health and Dental Center, Inc

Doing business as Canton Community Clinic

  • Federally Qualified Health Center (FQHC)
  • Canton, OH
National Provider Identifier
1851592034
Registry record updated May 2, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LIFECARE FAMILY HEALTH AND DENTAL CENTER, INC
Doing business as
Canton Community Clinic
Practice address
408 9TH St SW
Canton, OH 44707-4714
Phone
(330) 454-2000
Fax
(330) 454-7284
NPI assigned
May 29, 2007
Last updated
May 2, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 2, 2019

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

Authorized official

Name
Kathryn M Seeberger
Title
Chief Executive Officer
Phone
(330) 454-2000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X OH Primary

Addresses

Primary practice location

408 9TH St SW
Canton, OH 44707-4714

Mailing address

2725 Lincoln St E
Canton, OH 44707-2769
Phone (330) 454-2000

Other identifiers 1

IdentifierTypeStateIssuer
0099810MedicaidOH

Other names 1

  • CANTON COMMUNITY CLINIC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20131031001454 OH Part B Supplier - Clinic/Group Practice 7315959483 Receives reassigned benefits from 22 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Massillon, OH; Canton, OH
O20140117000859 OH Part A Provider - Federally Qualified Health Center (FQHC) 7315959483 Practice locations: Canton, OH

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1851592034. Details of each certification follow.

Federally qualified health center certification: CCN 361034

Legal name
LIFECARE FAMILY HEALTH AND DENTAL CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 17, 2014
Last certification
Jan 17, 2014
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Apr 3, 1992 in OH
Enrollment address
408 9TH St SW
Canton, OH 44707-4714

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 4

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
36D2035277Lifecare Family Health and Dental408 Ninth Street SW, Canton, OH 44707Certificate of waiverJan 12, 2028

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Eric Niemeyer Individual Corporate OfficerCeo Feb 7, 2022
W-2 Managing EmployeeCeo Feb 7, 2022
Dean Varian Individual Corporate OfficerChairman Oct 1, 2016
Corporate DirectorBoard Member Oct 1, 2016
Barbara Frustaci Individual Corporate OfficerChairman Jan 25, 2018
Corporate DirectorBoard Member Jan 25, 2018
Kelly Henley Individual Corporate OfficerTreasurer Jan 1, 2019
Corporate DirectorBoard Member Jan 1, 2019
George Crues Individual Corporate OfficerVice Chairman Jan 1, 2020
Corporate DirectorBoard Member Jan 1, 2020
Zach Hostetler Individual Corporate DirectorBoard Member Jan 1, 2019
Lora Harley Individual Corporate OfficerBoard Member Jan 1, 2023
Rebecca Johnson Individual Corporate OfficerBoard Member Jan 1, 2021
Terrance L Jones Individual Corporate OfficerBoard Member Jan 1, 2021
Rebekka Russell Individual Corporate OfficerBoard Member May 26, 2022
Gail Tarantino Individual Corporate OfficerBoard Member Jul 23, 2020
Allana Haut Individual Corporate DirectorBoard Member Jun 26, 2015

Practitioners & affiliated clinicians

Practitioners 24

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 24

NPI Registry JSON

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

{
    "created_epoch": "1180396800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1556755200000",
    "number": "1851592034",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2725 LINCOLN ST E",
            "city": "CANTON",
            "state": "OH",
            "postal_code": "447072769",
            "telephone_number": "330-454-2000",
            "fax_number": "330-454-7284"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "408 9TH ST SW",
            "city": "CANTON",
            "state": "OH",
            "postal_code": "447074714",
            "telephone_number": "330-454-2000",
            "fax_number": "330-454-7284"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFECARE FAMILY HEALTH AND DENTAL CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-29",
        "last_updated": "2019-05-02",
        "status": "A",
        "authorized_official_last_name": "SEEBERGER",
        "authorized_official_first_name": "KATHRYN",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "330-454-2000"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "OH",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0099810",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CANTON COMMUNITY CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canton, OH

Sources for this page

Verify at the official NPI Registry.