Provider Demographics
NPI:1477822377
Name:LAKE ASPEN PROFESSIONAL GROUP PS
Entity Type:Organization
Organization Name:LAKE ASPEN PROFESSIONAL GROUP PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:VLAHAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-575-7750
Mailing Address - Street 1:1460 N 16TH AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-7102
Mailing Address - Country:US
Mailing Address - Phone:509-575-7750
Mailing Address - Fax:509-575-7796
Practice Address - Street 1:1460 N 16TH AVE
Practice Address - Street 2:SUITE G
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7102
Practice Address - Country:US
Practice Address - Phone:509-575-7750
Practice Address - Fax:509-575-7796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014780261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7237209Medicaid
WA7237209Medicaid
WAE17999Medicare UPIN