Provider Demographics
NPI:1922085604
Name:LAKE COUNTY MEDICAL CLINIC, P.C.
Entity Type:Organization
Organization Name:LAKE COUNTY MEDICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FELDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-947-3366
Mailing Address - Street 1:624 S J ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1680
Mailing Address - Country:US
Mailing Address - Phone:541-947-3366
Mailing Address - Fax:541-947-4404
Practice Address - Street 1:624 S J ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1680
Practice Address - Country:US
Practice Address - Phone:541-947-3366
Practice Address - Fax:541-947-4404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR246694Medicaid
OR101626Medicare ID - Type Unspecified