1164711420 NPI number — LAKE PROSTHETICS AND RESEARCH, LLC

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 1164711420 NPI number — LAKE PROSTHETICS AND RESEARCH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE PROSTHETICS AND RESEARCH, LLC
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:
Provider Other Organization Name Type Code:
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:
1164711420
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 WESTPARK WAY
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
EULESS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76040-3964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-358-1500
Provider Business Mailing Address Fax Number:
682-224-8430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 WESTPARK WAY
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
EULESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76040-3964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-358-1500
Provider Business Practice Location Address Fax Number:
682-224-8430
Provider Enumeration Date:
04/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LAKE
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
CHIEF CLINICAL DIRECTOR
Authorized Official Telephone Number:
817-358-1500

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  80 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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