Provider Demographics
NPI:1417492091
Name:LAKE REGIONAL HEALTH SYSTEM
Entity Type:Organization
Organization Name:LAKE REGIONAL HEALTH SYSTEM
Other - Org Name:LAKE REGIONAL HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-348-8756
Mailing Address - Street 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:573-302-2860
Mailing Address - Fax:
Practice Address - Street 1:1029 NICHOLS RD STE A
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3702
Practice Address - Country:US
Practice Address - Phone:573-302-2860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO820052478Medicaid