Basic Information
| Provider Information | |||||||||
| NPI: | 1053427492 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE REGIONAL HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAKE REGIONAL CLINIC-ELDON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1500 | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650651500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733488074 | ||||||||
| FaxNumber: | 5733488069 | ||||||||
| Practice Location | |||||||||
| Address1: | 304A E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | ELDON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650261808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733925654 | ||||||||
| FaxNumber: | 5733925692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HALSELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. V.P., CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5733488388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 592540009 | 05 | MO | MEDICAID |