Basic Information
| Provider Information | |||||||||
| NPI: | 1750571758 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE CHELAN CLINIC, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P. O. BOX 368 | ||||||||
| Address2: | |||||||||
| City: | CHELAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096822511 | ||||||||
| FaxNumber: | 5096822515 | ||||||||
| Practice Location | |||||||||
| Address1: | 219 E. JOHNSON AVE. | ||||||||
| Address2: | |||||||||
| City: | CHELAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096822511 | ||||||||
| FaxNumber: | 5096822511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 10/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5096822511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 601677826 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.