Provider Demographics
NPI:1548222102
Name:LAKE FOREST PARK CLINIC TR
Entity Type:Organization
Organization Name:LAKE FOREST PARK CLINIC TR
Other - Org Name:LAKE FOREST PARK MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SCHNEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-368-1700
Mailing Address - Street 1:17191 BOTHELL WAY NE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5534
Mailing Address - Country:US
Mailing Address - Phone:206-365-6768
Mailing Address - Fax:206-364-5418
Practice Address - Street 1:17191 BOTHELL WAY NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-5534
Practice Address - Country:US
Practice Address - Phone:206-365-6768
Practice Address - Fax:206-364-5418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACJ6346OtherRAILROAD MEDICARE
GAB25977Medicare PIN
AB25977Medicare PIN