Provider Demographics
NPI:1841311529
Name:CITIZENS OF LAKE COUNTY FOR HEALTH CARE INC
Entity type:Organization
Organization Name:CITIZENS OF LAKE COUNTY FOR HEALTH CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ISBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-253-6690
Mailing Address - Street 1:710 CARL PERKINS PKWY
Mailing Address - Street 2:
Mailing Address - City:TIPTONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38079
Mailing Address - Country:US
Mailing Address - Phone:731-253-6690
Mailing Address - Fax:731-253-6692
Practice Address - Street 1:710 CARL PERKINS PKWY
Practice Address - Street 2:
Practice Address - City:TIPTONVILLE
Practice Address - State:TN
Practice Address - Zip Code:38079
Practice Address - Country:US
Practice Address - Phone:731-253-6690
Practice Address - Fax:731-253-6692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992848816OtherNPI DR. CAROL GUESS
TN444-7958Medicaid
1992848816OtherNPI DR. CAROL GUESS
TN441822Medicare ID - Type UnspecifiedLAKE COUNTY PRIMARY CARE