1780718916 NPI number — LAKEPOINT AUGUSTA, LLC

Table of content: (NPI 1780718916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780718916 NPI number — LAKEPOINT AUGUSTA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEPOINT AUGUSTA, 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:
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:
1780718916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 LAKEPOINT DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-776-2194
Provider Business Mailing Address Fax Number:
316-776-9370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 LAKEPOINT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67010-2423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-776-2194
Provider Business Practice Location Address Fax Number:
316-776-9370
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LAVALLEE
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
316-775-6333

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100108500B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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