Provider Demographics
NPI:1760802912
Name:LAKELAND IMMEDIATE CARE CENTER
Entity Type:Organization
Organization Name:LAKELAND IMMEDIATE CARE CENTER
Other - Org Name:NILES COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-445-3874
Mailing Address - Street 1:24 N SAINT JOSEPH AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2263
Mailing Address - Country:US
Mailing Address - Phone:269-262-4749
Mailing Address - Fax:269-262-4739
Practice Address - Street 1:24 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE G
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2263
Practice Address - Country:US
Practice Address - Phone:269-262-4749
Practice Address - Fax:269-262-4739
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKELAND IMMEDIATE CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)