Provider Demographics
NPI:1558609628
Name:CITIZENS OF LAKE COUNTY FOR HEALTH CARE, INC
Entity Type:Organization
Organization Name:CITIZENS OF LAKE COUNTY FOR HEALTH CARE, INC
Other - Org Name:LAUDERDALE COUNTY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:ISBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-253-6690
Mailing Address - Street 1:710 CARL PERKINS PKWY
Mailing Address - Street 2:
Mailing Address - City:TIPTONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38063
Mailing Address - Country:US
Mailing Address - Phone:731-253-6690
Mailing Address - Fax:731-253-6692
Practice Address - Street 1:317 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063
Practice Address - Country:US
Practice Address - Phone:731-221-1804
Practice Address - Fax:731-221-1880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITIZENS OF LAKE COUNTY FOR HEALTH CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)