1144298787 NPI number — THE LAKES COMMUNITY HEALTH CENTER, INC

Table of content: (NPI 1144298787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144298787 NPI number — THE LAKES COMMUNITY HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE LAKES COMMUNITY HEALTH CENTER, INC
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:
NORTHLAKES COMMUNITY CLINIC
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:
1144298787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15735 W US HIGHWAY 63
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYWARD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54843-6475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-934-0710
Provider Business Mailing Address Fax Number:
715-598-4881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11128 N STATE ROAD 77
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYWARD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54843-5332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-634-2541
Provider Business Practice Location Address Fax Number:
715-634-5740
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICE
Authorized Official First Name:
REBA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
715-372-5001

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1811178825 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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