Provider Demographics
NPI:1669648614
Name:LAKELAND FAMILY CLINIC PLLC
Entity Type:Organization
Organization Name:LAKELAND FAMILY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-939-9811
Mailing Address - Street 1:1000 LAKELAND SQUARE EXT
Mailing Address - Street 2:SUITE 800
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232
Mailing Address - Country:US
Mailing Address - Phone:601-939-9811
Mailing Address - Fax:601-939-7272
Practice Address - Street 1:1000 LAKELAND SQUARE EXT
Practice Address - Street 2:SUITE 800
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232
Practice Address - Country:US
Practice Address - Phone:601-939-9811
Practice Address - Fax:601-939-7272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08447207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD73502Medicare UPIN