1891242111 NPI number — THE LAKES COMMUNITY HEALTH CENTER, INC

Table of content: (NPI 1891242111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891242111 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:
1891242111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2021
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:
320 SUPERIOR AVE STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHBURN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54891-9428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-373-2233
Provider Business Practice Location Address Fax Number:
715-373-5530
Provider Enumeration Date:
09/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
AHLGREN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
715-934-3056

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".




Copyright © 2007-2024 www.npivalidator.com