Healthcare Provider Details

I. General information

NPI: 1982514592
Provider Name (Legal Business Name): LAKE CITY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 N LAKEWOOD DR
COEUR D ALENE ID
83814-2633
US

IV. Provider business mailing address

1916 N LAKEWOOD DR
COEUR D ALENE ID
83814-2633
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-4628
  • Fax: 208-667-6695
Mailing address:
  • Phone: 208-667-4628
  • Fax: 208-667-6695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. VARUNEE PHILLIPS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 208-667-4628