Provider Demographics
NPI:1639247034
Name:LAKE, ROSS (ROSS LAKE)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:LAKE
Suffix:
Gender:M
Credentials:ROSS LAKE
Other - Prefix:
Other - First Name:ROSS
Other - Middle Name:
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:236 S HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-3514
Mailing Address - Country:US
Mailing Address - Phone:707-459-2488
Mailing Address - Fax:707-459-2228
Practice Address - Street 1:236 S HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-3514
Practice Address - Country:US
Practice Address - Phone:707-459-2488
Practice Address - Fax:707-459-2228
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2909171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist