Basic Information
| Provider Information | |||||||||
| NPI: | 1669790200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHEFF | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | R. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 880 | ||||||||
| Address2: | |||||||||
| City: | ST IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067454233 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 MISSION DRIVE | ||||||||
| Address2: | |||||||||
| City: | ST IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453575 | ||||||||
| FaxNumber: | 4067454233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2010 | ||||||||
| LastUpdateDate: | 05/06/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247100000X | 2969 | MT | Y | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist |
No ID Information.