Provider Demographics
NPI:1508391079
Name:LAKE AREA FREE CLINIC
Entity Type:Organization
Organization Name:LAKE AREA FREE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:REICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-569-4990
Mailing Address - Street 1:856 B ARMOUR ROAD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:50366
Mailing Address - Country:US
Mailing Address - Phone:262-569-4990
Mailing Address - Fax:
Practice Address - Street 1:856 B ARMOUR ROAD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:50366
Practice Address - Country:US
Practice Address - Phone:262-569-4990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable