Provider Demographics
NPI:1619593944
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:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:MARIE
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:38079-1678
Mailing Address - Country:US
Mailing Address - Phone:731-253-6690
Mailing Address - Fax:
Practice Address - Street 1:321 E HARPER ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:TN
Practice Address - Zip Code:38260
Practice Address - Country:US
Practice Address - Phone:731-442-0956
Practice Address - Fax:731-253-6692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)