Provider Demographics
NPI:1841788536
Name:LAK SAM INC
Entity Type:Organization
Organization Name:LAK SAM INC
Other - Org Name:LAK TRANSPORTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTH
Authorized Official - Middle Name:P
Authorized Official - Last Name:PATHTHAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-300-7819
Mailing Address - Street 1:19B HARTMAN RD
Mailing Address - Street 2:
Mailing Address - City:GLENMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12077-4418
Mailing Address - Country:US
Mailing Address - Phone:518-300-7819
Mailing Address - Fax:
Practice Address - Street 1:19B HARTMAN RD
Practice Address - Street 2:
Practice Address - City:GLENMONT
Practice Address - State:NY
Practice Address - Zip Code:12077-4418
Practice Address - Country:US
Practice Address - Phone:518-300-7819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04572414343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherMEDICAID TRANSPORTAION