Provider Demographics
NPI:1952761710
Name:GOOSE LAKE MEDICAL SERVICES INC
Entity Type:Organization
Organization Name:GOOSE LAKE MEDICAL SERVICES INC
Other - Org Name:LAKE HEALTH MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TVEIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-947-2114
Mailing Address - Street 1:700 S J ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1623
Mailing Address - Country:US
Mailing Address - Phone:541-947-2114
Mailing Address - Fax:541-947-2433
Practice Address - Street 1:16 N F ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1528
Practice Address - Country:US
Practice Address - Phone:541-947-2370
Practice Address - Fax:541-947-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR7562260001Medicare NSC