Provider Demographics
NPI:1053665091
Name:LAKESIDE CLINIC P.C.
Entity Type:Organization
Organization Name:LAKESIDE CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:B
Authorized Official - Last Name:RIPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:406-857-2997
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:MT
Mailing Address - Zip Code:59922-0649
Mailing Address - Country:US
Mailing Address - Phone:406-857-2997
Mailing Address - Fax:406-857-2044
Practice Address - Street 1:77 DEER CREEK RD
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:MT
Practice Address - Zip Code:59932-8000
Practice Address - Country:US
Practice Address - Phone:406-857-2997
Practice Address - Fax:406-857-2044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care