Provider Demographics
NPI:1114917309
Name:LAKE NORMAN MEDICAL EQUIPMENT
Entity Type:Organization
Organization Name:LAKE NORMAN MEDICAL EQUIPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:P
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-838-0587
Mailing Address - Street 1:693 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROUTMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28166
Mailing Address - Country:US
Mailing Address - Phone:704-838-0587
Mailing Address - Fax:704-838-0589
Practice Address - Street 1:693 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TROUTMAN
Practice Address - State:NC
Practice Address - Zip Code:28166
Practice Address - Country:US
Practice Address - Phone:704-838-0587
Practice Address - Fax:704-838-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703510Medicaid
NC7703510Medicaid