Basic Information
Provider Information | |||||||||
NPI: | 1679983423 | ||||||||
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: | 15954 RIVERS EDGE DR | ||||||||
Address2: |   | ||||||||
City: | HAYWARD | ||||||||
State: | WI | ||||||||
PostalCode: | 548437800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156342541 | ||||||||
FaxNumber: | 7155984881 | ||||||||
Practice Location | |||||||||
Address1: | 524 BISSELL STREET | ||||||||
Address2: |   | ||||||||
City: | WHITE LAKE | ||||||||
State: | WI | ||||||||
PostalCode: | 54491 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152766321 | ||||||||
FaxNumber: | 7152761482 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2014 | ||||||||
LastUpdateDate: | 03/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RICE | ||||||||
AuthorizedOfficialFirstName: | REBA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7153725001 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | WI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.