Basic Information
Provider Information | |||||||||
NPI: | 1659884716 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE LAKES COMMUNITY HEALTH CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTHLAKES COMMUNITY CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15735 W US HIGHWAY 63 | ||||||||
Address2: |   | ||||||||
City: | HAYWARD | ||||||||
State: | WI | ||||||||
PostalCode: | 548436475 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7159340710 | ||||||||
FaxNumber: | 7155984881 | ||||||||
Practice Location | |||||||||
Address1: | 15954 RIVERS EDGE DR STE 304 | ||||||||
Address2: |   | ||||||||
City: | HAYWARD | ||||||||
State: | WI | ||||||||
PostalCode: | 548437800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156342541 | ||||||||
FaxNumber: | 7155984881 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2017 | ||||||||
LastUpdateDate: | 08/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RICE | ||||||||
AuthorizedOfficialFirstName: | REBA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7153725001 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1811178825 | 05 | WI |   | MEDICAID |