Provider Demographics
NPI:1063855211
Name:ANGUS LAKE INFUSION SERVICES
Entity Type:Organization
Organization Name:ANGUS LAKE INFUSION SERVICES
Other - Org Name:ANGUS LAKE VITAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:LAKE
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:478-387-2399
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:31031-0249
Mailing Address - Country:US
Mailing Address - Phone:478-387-2399
Mailing Address - Fax:478-628-2263
Practice Address - Street 1:240 MILLEDGEVILLE RD
Practice Address - Street 2:SUITE B
Practice Address - City:GORDON
Practice Address - State:GA
Practice Address - Zip Code:31031-3827
Practice Address - Country:US
Practice Address - Phone:478-387-2399
Practice Address - Fax:478-628-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHHH000055332B00000X, 332BP3500X, 3336C0004X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137168AMedicaid