Provider Demographics
NPI:1689863714
Name:LAKE MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:LAKE MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-471-2033
Mailing Address - Street 1:1146 SAN MARINO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4649
Mailing Address - Country:US
Mailing Address - Phone:760-471-2033
Mailing Address - Fax:760-471-2083
Practice Address - Street 1:1146 SAN MARINO DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4649
Practice Address - Country:US
Practice Address - Phone:760-471-2033
Practice Address - Fax:760-471-2083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17617111N00000X
CAG263822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42992Medicare UPIN
CADC17617Medicare PIN
CADC17616Medicare PIN
CAG26382Medicare PIN
CADC17419Medicare PIN