Provider Demographics
NPI:1376646380
Name:COUNTY OF LAKE
Entity Type:Organization
Organization Name:COUNTY OF LAKE
Other - Org Name:LAKE COUNTY PUBLIC HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILKIE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:541-947-6045
Mailing Address - Street 1:100 N D ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1540
Mailing Address - Country:US
Mailing Address - Phone:541-947-6045
Mailing Address - Fax:541-947-4563
Practice Address - Street 1:100 N D ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1540
Practice Address - Country:US
Practice Address - Phone:541-947-6045
Practice Address - Fax:541-947-4563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WC1500X, 261QA0005X, 261QP0905X
OR93-60023202251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR01358700OtherBLUE CROSS PROVIDER NUMBE
OR320989OtherOMAP FAMILY PLANNING PIN
OR097360OtherOMAP PIN
OR320989OtherOMAP PROVIDERS
OR=========OtherTAX ID
ORMD21779Medicare UPIN