Provider Demographics
NPI:1649432980
Name:LAKELAND FAMILY CARE OF NILES
Entity type:Organization
Organization Name:LAKELAND FAMILY CARE OF NILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P OPERATIONS PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8574
Mailing Address - Street 1:4 LONGMEADOW VILLAGE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-7809
Mailing Address - Country:US
Mailing Address - Phone:269-684-6000
Mailing Address - Fax:269-684-1388
Practice Address - Street 1:4 LONGMEADOW VILLAGE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-7809
Practice Address - Country:US
Practice Address - Phone:269-684-6000
Practice Address - Fax:269-684-1388
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUR FLAGS HEALTH VENTURE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-27
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty