Basic Information
| Provider Information | |||||||||
| NPI: | 1902352206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LACUNA FAMILY MEDICINE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2816 | ||||||||
| Address2: | |||||||||
| City: | SEWARD | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996642816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074910645 | ||||||||
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| Practice Location | |||||||||
| Address1: | 204 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEWARD | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074910645 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2016 | ||||||||
| LastUpdateDate: | 08/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | FLYNN | ||||||||
| AuthorizedOfficialFirstName: | JERALD | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9074910645 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 1038449 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | MD9543 | 05 | AK | MEDICAID |