Provider Demographics
NPI:1073956223
Name:THE LAKES COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:THE LAKES COMMUNITY HEALTH CENTER, INC
Other - Org Name:NORTHLAKES COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REBA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-372-5001
Mailing Address - Street 1:15735 W US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-6475
Mailing Address - Country:US
Mailing Address - Phone:715-934-0710
Mailing Address - Fax:715-598-4881
Practice Address - Street 1:820 ARBUTUS AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-2004
Practice Address - Country:US
Practice Address - Phone:920-516-7107
Practice Address - Fax:920-835-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4757-800261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1811178825Medicaid