Basic Information
| Provider Information | |||||||||
| NPI: | 1417492091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE REGIONAL HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE REGIONAL HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733022860 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1193 HIGHWAY KK | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733022860 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2017 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | HALSELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5733488388 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
No ID Information.