Basic Information
| Provider Information | |||||||||
| NPI: | 1053665091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESIDE CLINIC P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 649 | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599220649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068572997 | ||||||||
| FaxNumber: | 4068572044 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 DEER CREEK RD | ||||||||
| Address2: | |||||||||
| City: | SOMERS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599328000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068572997 | ||||||||
| FaxNumber: | 4068572044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2012 | ||||||||
| LastUpdateDate: | 05/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | RIPLEY | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4068572997 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.