Basic Information
| Provider Information | |||||||||
| NPI: | 1134898505 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 42 N SAINT JOSEPH AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491202203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696872910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2021 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | KONOPACKI | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCE, VP | ||||||||
| AuthorizedOfficialTelephone: | 6164869305 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 332S00000X | N | Suppliers | Hearing Aid Equipment | 231H00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.