1578678660 NPI number — LAKE AREA MANAGEMENT GROUP

Table of content: (NPI 1578678660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578678660 NPI number — LAKE AREA MANAGEMENT GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE AREA MANAGEMENT GROUP
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 AREA THERAPY & REHABILITATION
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:
1578678660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1442 KINGWOOD DR PMB 73
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77339-3040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-354-1234
Provider Business Mailing Address Fax Number:
281-354-2514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 BYPASS LN STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVINGSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77351-7380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-327-8825
Provider Business Practice Location Address Fax Number:
936-328-8724
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DELOACH
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
936-327-8825

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0038JC . This is a "BC/BS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00190698 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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