Provider Demographics
NPI:1396239562
Name:LAKELAND MEDICAL PRACTICES
Entity type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8282
Mailing Address - Street 1:2500 NILES AVE.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST. JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-983-3380
Mailing Address - Fax:269-985-0353
Practice Address - Street 1:2500 NILES AVE.
Practice Address - Street 2:SUITE 1
Practice Address - City:ST. JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-983-3380
Practice Address - Fax:269-985-0353
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKELAND MEDICAL PRACTICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty