Basic Information
| Provider Information | |||||||||
| NPI: | 1275873424 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE COUNTY PRIMARY CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 CARL PERKINS PKWY | ||||||||
| Address2: | |||||||||
| City: | TIPTONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380791678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312536690 | ||||||||
| FaxNumber: | 7312536692 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 CARL PERKINS PKWY | ||||||||
| Address2: | |||||||||
| City: | TIPTONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380791678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312536690 | ||||||||
| FaxNumber: | 7312536692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2013 | ||||||||
| LastUpdateDate: | 02/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | GUESS | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | WINFRED | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7312536690 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MEDICAL DOCTOR | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 17394 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.