1659343622 NPI number — LAKELAND PROFESSIONAL SERVICES, INC

Table of content: (NPI 1659343622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659343622 NPI number — LAKELAND PROFESSIONAL SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKELAND PROFESSIONAL SERVICES, 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:
Provider Other Organization Name Type Code:
6
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:
1659343622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 LONG MEADOW VILLAGE LN
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
NILES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49120-7808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-684-6000
Provider Business Mailing Address Fax Number:
269-684-1388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 LONG MEADOW VILLAGE LN
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
NILES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49120-7808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-684-6000
Provider Business Practice Location Address Fax Number:
269-684-1388
Provider Enumeration Date:
02/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIDDLETON
Authorized Official First Name:
MARY
Authorized Official Middle Name:
GEEGAN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
269-684-0259

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CN2908 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: OA110150 . This is a "BC BS GROUP #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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