Provider Demographics
NPI:1114328614
Name:LAKELAND IMMEDIATE CARE CENTER
Entity Type:Organization
Organization Name:LAKELAND IMMEDIATE CARE CENTER
Other - Org Name:CASSOPOLIS FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-445-3874
Mailing Address - Street 1:261 M 62
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-1034
Mailing Address - Country:US
Mailing Address - Phone:269-228-8505
Mailing Address - Fax:269-445-1911
Practice Address - Street 1:261 M 62
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-1034
Practice Address - Country:US
Practice Address - Phone:269-228-8505
Practice Address - Fax:269-445-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010105973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114328614Medicaid
2147873OtherPK