Provider Demographics
NPI:1740260892
Name:LAKE HILLS MEDICAL ASSOC
Entity type:Organization
Organization Name:LAKE HILLS MEDICAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-798-8968
Mailing Address - Street 1:1525 BURRELL DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5827
Mailing Address - Country:US
Mailing Address - Phone:208-816-1332
Mailing Address - Fax:
Practice Address - Street 1:14858 LAKE HILLS BLVD
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-5821
Practice Address - Country:US
Practice Address - Phone:208-816-1332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7081771Medicaid
WA7081771Medicaid