Provider Demographics
NPI:1952924896
Name:W. LAFAYETTE HEALTH CENTER
Entity Type:Organization
Organization Name:W. LAFAYETTE HEALTH CENTER
Other - Org Name:LAFAYETTE DPC-1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF MEDICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KEMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-501-0815
Mailing Address - Street 1:10 CENTIMETERS DR
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-3278
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:
Practice Address - Street 1:2701B KENT AVE
Practice Address - Street 2:
Practice Address - City:W LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1350
Practice Address - Country:US
Practice Address - Phone:812-308-8400
Practice Address - Fax:765-600-9796
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROACTIVE MSO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-27
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care