Provider Demographics
NPI:1619193653
Name:SOUTH LAKE MEDICAL CENTER INC.
Entity Type:Organization
Organization Name:SOUTH LAKE MEDICAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVERETT
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:626-449-6915
Mailing Address - Street 1:213 S. EUCLID AVE.
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2717
Mailing Address - Country:US
Mailing Address - Phone:626-449-8314
Mailing Address - Fax:
Practice Address - Street 1:213 S. EUCLID AVE.
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2717
Practice Address - Country:US
Practice Address - Phone:626-449-8314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7583180001Medicare NSC