Provider Demographics
NPI:1922011667
Name:COUNTY OF LAKE
Entity Type:Organization
Organization Name:COUNTY OF LAKE
Other - Org Name:LAKE COUNTY HEALTH DEPARTMENT AND COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PFISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-377-8000
Mailing Address - Street 1:3010 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2321
Mailing Address - Country:US
Mailing Address - Phone:847-377-8000
Mailing Address - Fax:847-360-2938
Practice Address - Street 1:3010 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2321
Practice Address - Country:US
Practice Address - Phone:847-377-8050
Practice Address - Fax:847-360-2938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========006Medicaid