Provider Demographics
NPI:1275873424
Name:LAKE COUNTY PRIMARY CARE
Entity Type:Organization
Organization Name:LAKE COUNTY PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:WINFRED
Authorized Official - Last Name:GUESS
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:731-253-6690
Mailing Address - Street 1:710 CARL PERKINS PKWY
Mailing Address - Street 2:
Mailing Address - City:TIPTONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38079-1678
Mailing Address - Country:US
Mailing Address - Phone:731-253-6690
Mailing Address - Fax:731-253-6692
Practice Address - Street 1:710 CARL PERKINS PKWY
Practice Address - Street 2:
Practice Address - City:TIPTONVILLE
Practice Address - State:TN
Practice Address - Zip Code:38079-1678
Practice Address - Country:US
Practice Address - Phone:731-253-6690
Practice Address - Fax:731-253-6692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17394261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)