MEDICARE: LAKE CONVENIENCE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1174516249
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE CONVENIENCE CLINIC

Provider Business Mailing Address
First Line	:	100 COLLEGE BLVD
Second Line	:
City	:	LAKE OZARK
State	:	MO
Zip	:	65049-8690
Country	:	US
Telephone Number	:	573-348-1560
Fax Number	:	573-348-5088

Provider Business Practice Location Address
First Line	:	100 COLLEGE BLVD
Second Line	:
City	:	LAKE OZARK
State	:	MO
Zip	:	65049-8690
Country	:	US
Telephone Number	:	573-348-1560
Fax Number	:	573-348-5088

Authorized Official
Title or Position	:	DOCTOR
Name	:	THOMAS HENRY GARRETT
Credential	:	MD
Telephone Number	:	573-398-1560

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	07/03/2008

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Directions to “LAKE CONVENIENCE CLINIC ” Practice Location

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