1437440856 NPI number — LAKE REGIONAL HEALTH SYSTEM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437440856 NPI number — LAKE REGIONAL HEALTH SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE REGIONAL HEALTH SYSTEM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKE REGIONAL CLINIC - CAMDENTON
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437440856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 801661
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-1661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-348-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1930 N BUSINESS ROUTE 5
Provider Second Line Business Practice Location Address:
UNIT 1A
Provider Business Practice Location Address City Name:
CAMDENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65020-2659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-346-5624
Provider Business Practice Location Address Fax Number:
573-346-1957
Provider Enumeration Date:
04/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MCROBERTS
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
573-348-8756

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1437440856 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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