Provider Demographics
NPI:1740255520
Name:LAKE REGIONAL HEALTH SYSTEM
Entity type:Organization
Organization Name:LAKE REGIONAL HEALTH SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-348-8756
Mailing Address - Street 1:54 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:573-348-8000
Mailing Address - Fax:573-348-8326
Practice Address - Street 1:1029 NICHOLS RD STE A
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3702
Practice Address - Country:US
Practice Address - Phone:573-302-2860
Practice Address - Fax:573-348-8326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO583558804Medicaid
MO583558804Medicaid