Basic Information
| Provider Information | |||||||||
| NPI: | 1750878542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE LAKES COMMUNITY HEALTH CENTER, INC | ||||||||
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| OtherOrganizationName: | NORTHLAKES COMMUNITY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15954 RIVERS EDGE DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548437894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | 7155984881 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BIRCHWOOD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153543369 | ||||||||
| FaxNumber: | 7153547158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2018 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | RICE | ||||||||
| AuthorizedOfficialFirstName: | REBA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7153725001 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |