Provider Demographics
NPI:1750878542
Name:THE LAKES COMMUNITY HEALTH CENTER, INC
Entity type:Organization
Organization Name:THE LAKES COMMUNITY HEALTH CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REBA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-372-5001
Mailing Address - Street 1:15954 RIVERS EDGE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-7894
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:715-598-4881
Practice Address - Street 1:108 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BIRCHWOOD
Practice Address - State:WI
Practice Address - Zip Code:54817
Practice Address - Country:US
Practice Address - Phone:715-354-3369
Practice Address - Fax:715-354-7158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1811178825Medicaid