Provider Demographics
NPI:1851697817
Name:CITIZENS OF LAKE COUNTY FOR HEALTH CARE INC
Entity Type:Organization
Organization Name:CITIZENS OF LAKE COUNTY FOR HEALTH CARE INC
Other - Org Name:WILLIAM B, ACREE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAYANNE
Authorized Official - Middle Name:CARTWRIGHT
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-253-6690
Mailing Address - Street 1:130 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RIDGELY
Mailing Address - State:TN
Mailing Address - Zip Code:38080-1317
Mailing Address - Country:US
Mailing Address - Phone:731-264-5518
Mailing Address - Fax:731-264-6859
Practice Address - Street 1:130 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RIDGELY
Practice Address - State:TN
Practice Address - Zip Code:38080-1317
Practice Address - Country:US
Practice Address - Phone:731-264-5518
Practice Address - Fax:731-264-6859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6899261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN441827Medicare PIN