Provider Demographics
NPI:1952896151
Name:LAKE CITY PRIMARY CARE PC
Entity Type:Organization
Organization Name:LAKE CITY PRIMARY CARE PC
Other - Org Name:LAKE CITY PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-908-8888
Mailing Address - Street 1:1866 S MOREY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651-9190
Mailing Address - Country:US
Mailing Address - Phone:231-830-7282
Mailing Address - Fax:231-830-7222
Practice Address - Street 1:1866 S MOREY RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651
Practice Address - Country:US
Practice Address - Phone:231-908-8888
Practice Address - Fax:833-989-2153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-29
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238938Medicaid
MIMI12315Medicaid