Provider Demographics
NPI:1326187261
Name:LAKE HEALTH DISTRICT
Entity Type:Organization
Organization Name:LAKE HEALTH DISTRICT
Other - Org Name:LAKE WOUND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:ENSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-947-2114
Mailing Address - Street 1:700 S J ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1623
Mailing Address - Country:US
Mailing Address - Phone:541-947-7299
Mailing Address - Fax:541-947-3339
Practice Address - Street 1:670 COUNTY RD 83
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:CA
Practice Address - Zip Code:96015
Practice Address - Country:US
Practice Address - Phone:541-947-7299
Practice Address - Fax:541-947-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14-0896261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center