Provider Demographics
NPI:1659343622
Name:LAKELAND PROFESSIONAL SERVICES, INC
Entity Type:Organization
Organization Name:LAKELAND PROFESSIONAL SERVICES, INC
Other - Org Name:FAMILY CARE OF NILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:GEEGAN
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-684-0259
Mailing Address - Street 1:4 LONG MEADOW VILLAGE LN
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-7808
Mailing Address - Country:US
Mailing Address - Phone:269-684-6000
Mailing Address - Fax:269-684-1388
Practice Address - Street 1:4 LONG MEADOW VILLAGE LN
Practice Address - Street 2:SUITE 2
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-7808
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:2006-02-03
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN2908OtherRAILROAD MEDICARE
MIOA110150OtherBC BS GROUP #
OM44080Medicare PIN