Provider Demographics
NPI:1578125647
Name:FAMILY CLINIC AT THE LAKE PLLC
Entity Type:Organization
Organization Name:FAMILY CLINIC AT THE LAKE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLANIKOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:731-689-4357
Mailing Address - Street 1:PO BOX 140
Mailing Address - Street 2:
Mailing Address - City:PICKWICK DAM
Mailing Address - State:TN
Mailing Address - Zip Code:38365-0140
Mailing Address - Country:US
Mailing Address - Phone:731-689-4357
Mailing Address - Fax:731-689-1050
Practice Address - Street 1:11268 HIGHWAY 57
Practice Address - Street 2:
Practice Address - City:COUNCE
Practice Address - State:TN
Practice Address - Zip Code:38326-3802
Practice Address - Country:US
Practice Address - Phone:731-689-4357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-28
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty