Basic Information
| Provider Information | |||||||||
| NPI: | 1851697817 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITIZENS OF LAKE COUNTY FOR HEALTH CARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WILLIAM B, ACREE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | RIDGELY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380801317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312645518 | ||||||||
| FaxNumber: | 7312646859 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIDGELY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380801317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312645518 | ||||||||
| FaxNumber: | 7312646859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 02/08/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | GAYANNE | ||||||||
| AuthorizedOfficialMiddleName: | CARTWRIGHT | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7312536690 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 6899 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.