Provider Demographics
NPI:1225237563
Name:LAKES MEDICAL CLINIC
Entity Type:Organization
Organization Name:LAKES MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-357-0820
Mailing Address - Street 1:PO BOX 876009
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-6009
Mailing Address - Country:US
Mailing Address - Phone:907-357-0820
Mailing Address - Fax:907-357-0821
Practice Address - Street 1:5050 DUNBAR STREET
Practice Address - Street 2:SUITE D
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-357-0820
Practice Address - Fax:907-357-0821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1154418945OtherNPI # DR. CHARLES D. LAYM
AK1083701858OtherNPI # GERALD EDWARD MANNI