Provider Demographics
NPI:1669647152
Name:LAKE WILDERNESS MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:LAKE WILDERNESS MEDICAL CLINIC LLC
Other - Org Name:CHET JANGALA, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:EDMOND
Authorized Official - Last Name:JANGALA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:425-432-9611
Mailing Address - Street 1:PO BOX 1142
Mailing Address - Street 2:
Mailing Address - City:RAVENSDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98051-1142
Mailing Address - Country:US
Mailing Address - Phone:425-432-9611
Mailing Address - Fax:206-973-5399
Practice Address - Street 1:26907 MAPLE VALLEY BLACK DIAMOND RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8314
Practice Address - Country:US
Practice Address - Phone:425-432-9611
Practice Address - Fax:206-973-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602777613261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty