Provider Demographics
NPI:1700106689
Name:LAKELAND MEDICAL PRACTICE
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICE
Other - Org Name:LAKELAND ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-687-1152
Mailing Address - Street 1:6 LONGMEADOW VILLAGE DR
Mailing Address - Street 2:SUITE1
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-7810
Mailing Address - Country:US
Mailing Address - Phone:269-684-6484
Mailing Address - Fax:269-684-6685
Practice Address - Street 1:6 LONGMEADOW VILLAGE DR
Practice Address - Street 2:SUITE1
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-7810
Practice Address - Country:US
Practice Address - Phone:269-684-6484
Practice Address - Fax:269-684-6685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center