Provider Demographics
NPI:1104859347
Name:LAKE COUNTY HEALTH SERVICES DEPARTMENT
Entity Type:Organization
Organization Name:LAKE COUNTY HEALTH SERVICES DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:707-263-8929
Mailing Address - Street 1:922 BEVINS CT
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-9754
Mailing Address - Country:US
Mailing Address - Phone:707-263-8929
Mailing Address - Fax:707-263-1662
Practice Address - Street 1:922 BEVINS CT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8929
Practice Address - Fax:707-263-1662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEXE70121FMedicaid
CAEXE70106FMedicaid