Basic Information
| Provider Information | |||||||||
| NPI: | 1174814545 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE REGIONAL MEDICAL MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE REGIONAL URGENT CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 5816 HWY 54 | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733023200 | ||||||||
| FaxNumber: | 5733023210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 04/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | PRENGER | ||||||||
| AuthorizedOfficialFirstName: | KRISTEN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5733488162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.