Provider Demographics
NPI:1376863407
Name:LAKELAND MEDICAL PRACTICES
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:LAKELAND COMPREHENSIVE WEIGHT LOSS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-687-1152
Mailing Address - Street 1:6416 DEANS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERRIEN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49102-9750
Mailing Address - Country:US
Mailing Address - Phone:269-687-4673
Mailing Address - Fax:269-687-1798
Practice Address - Street 1:42 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2208
Practice Address - Country:US
Practice Address - Phone:269-687-4673
Practice Address - Fax:269-687-1798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-11
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicare PIN