Provider Demographics
NPI:1508155870
Name:LAKE, JOSEPH CHRISTOPHER (L/CPO, FAAOP)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:CHRISTOPHER
Last Name:LAKE
Suffix:
Gender:M
Credentials:L/CPO, FAAOP
Other - Prefix:
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Mailing Address - Street 1:350 WESTPARK WAY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3964
Mailing Address - Country:US
Mailing Address - Phone:817-358-1500
Mailing Address - Fax:682-224-8430
Practice Address - Street 1:350 WESTPARK WAY
Practice Address - Street 2:SUITE 108
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3964
Practice Address - Country:US
Practice Address - Phone:817-358-1500
Practice Address - Fax:682-224-8430
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6539340001Medicare NSC