Provider Demographics
NPI:1114195419
Name:LAKES REGION HEALTHCARE
Entity Type:Organization
Organization Name:LAKES REGION HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BEAUREGARD
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:802-468-8755
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:BOMOSEEN
Mailing Address - State:VT
Mailing Address - Zip Code:05732-0509
Mailing Address - Country:US
Mailing Address - Phone:802-468-8755
Mailing Address - Fax:
Practice Address - Street 1:49 CASTLETON MEADOWS LN
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:VT
Practice Address - Zip Code:05735-9011
Practice Address - Country:US
Practice Address - Phone:802-468-8755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030883261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000153Medicaid
S94168Medicare UPIN
VT9000153Medicaid