Healthcare Provider Details

I. General information

NPI: 1710584388
Provider Name (Legal Business Name): LAKE HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18990 COYOTE VALLEY RD STE 2&3
HIDDEN VALLEY LAKE CA
95467-8337
US

IV. Provider business mailing address

PO BOX 7150
CLEARLAKE CA
95422-7150
US

V. Phone/Fax

Practice location:
  • Phone: 707-994-3141
  • Fax:
Mailing address:
  • Phone: 707-994-3141
  • Fax: 707-994-7150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. TIM NGUYEN
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 925-586-2112