Provider Demographics
NPI:1346754462
Name:LAKE DISTRICT HEALTH
Entity Type:Organization
Organization Name:LAKE DISTRICT HEALTH
Other - Org Name:N/A
Other - Org Type:Other Name
Authorized Official - Title/Position:QMHA
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:HALL
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-947-6021
Mailing Address - Street 1:215 N G ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1417
Mailing Address - Country:US
Mailing Address - Phone:547-947-6021
Mailing Address - Fax:
Practice Address - Street 1:215 N G ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1417
Practice Address - Country:US
Practice Address - Phone:547-947-6021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management