Provider Demographics
NPI:1811274525
Name:MEDINA LAKE CLINIC PA
Entity type:Organization
Organization Name:MEDINA LAKE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHLLEPPEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-751-3330
Mailing Address - Street 1:146 LAUREL VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LAKEHILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78063-6389
Mailing Address - Country:US
Mailing Address - Phone:830-751-3330
Mailing Address - Fax:
Practice Address - Street 1:146 LAUREL VISTA DR
Practice Address - Street 2:
Practice Address - City:LAKEHILLS
Practice Address - State:TX
Practice Address - Zip Code:78063-6389
Practice Address - Country:US
Practice Address - Phone:713-292-6959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB143461Medicare PIN