Provider Demographics
NPI:1093866048
Name:INTER LAKES MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:INTER LAKES MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUGHNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-585-3700
Mailing Address - Street 1:1019 WICKER ST
Mailing Address - Street 2:
Mailing Address - City:TICONDEROGA
Mailing Address - State:NY
Mailing Address - Zip Code:12883-1039
Mailing Address - Country:US
Mailing Address - Phone:518-585-3734
Mailing Address - Fax:518-585-2334
Practice Address - Street 1:1019 WICKER ST
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-1039
Practice Address - Country:US
Practice Address - Phone:518-585-3734
Practice Address - Fax:518-585-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02410819Medicaid
NY02410819Medicaid