Basic Information
| Provider Information | |||||||||
| NPI: | 1427088582 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEMONT FAMILY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601067 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9802122680 | ||||||||
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| Practice Location | |||||||||
| Address1: | 447 MCALISTER RD | ||||||||
| Address2: | |||||||||
| City: | LINCOLNTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280924114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9802122680 | ||||||||
| FaxNumber: | 7047323297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAYMON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7044468250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1427088582 | 01 | NC | NC MEDICAID DME | OTHER | 1427088582 | 05 | NC | MEDICAID |