Provider Demographics
NPI:1629397534
Name:LAKELAND MEDICAL PRACTICES
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:LAKELAND FAMILY CARE OF NILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXCUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8304
Mailing Address - Street 1:4 LONGMEADOW VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-7809
Mailing Address - Country:US
Mailing Address - Phone:269-684-6000
Mailing Address - Fax:269-684-1388
Practice Address - Street 1:4 LONGMEADOW VILLAGE DR
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-7809
Practice Address - Country:US
Practice Address - Phone:269-684-6000
Practice Address - Fax:269-684-1388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicare PIN