Provider Demographics
NPI:1669607792
Name:NORTH LAKE CLINIC, LLC
Entity type:Organization
Organization Name:NORTH LAKE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-576-2343
Mailing Address - Street 1:PO BOX 377
Mailing Address - Street 2:
Mailing Address - City:CHRISTMAS VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97641-0377
Mailing Address - Country:US
Mailing Address - Phone:541-576-2343
Mailing Address - Fax:541-576-2869
Practice Address - Street 1:87520 BAY RD
Practice Address - Street 2:
Practice Address - City:CHRISTMAS VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97641-0377
Practice Address - Country:US
Practice Address - Phone:541-576-2343
Practice Address - Fax:541-576-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD07786261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
080385000OtherBCBS OF OREGON
OR182817Medicaid
OR0000WCNHXMedicare PIN