Provider Demographics
NPI:1700234929
Name:INNERCHANGE LAKE HOUSE ACADEMY
Entity Type:Organization
Organization Name:INNERCHANGE LAKE HOUSE ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-229-5498
Mailing Address - Street 1:86 N UNIVERSITY AVE
Mailing Address - Street 2:#450
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-4420
Mailing Address - Country:US
Mailing Address - Phone:435-229-5498
Mailing Address - Fax:
Practice Address - Street 1:447 LILLY PAD LN
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:NC
Practice Address - Zip Code:28731-9503
Practice Address - Country:US
Practice Address - Phone:435-229-5498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNERCHANGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty