Provider Demographics
NPI:1639401771
Name:LAKE MANAGEMENT GROUP
Entity Type:Organization
Organization Name:LAKE MANAGEMENT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:ESCOBAR
Authorized Official - Last Name:DOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-831-4131
Mailing Address - Street 1:127 AUGUSTA DR
Mailing Address - Street 2:
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-2515
Mailing Address - Country:US
Mailing Address - Phone:210-831-4131
Mailing Address - Fax:
Practice Address - Street 1:127 AUGUSTA DR
Practice Address - Street 2:
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-2515
Practice Address - Country:US
Practice Address - Phone:210-831-4131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-30
Last Update Date:2010-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies