Healthcare Provider Details

I. General information

NPI: 1417493545
Provider Name (Legal Business Name): LAKELAND MEDICAL PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 NILES RD
SAINT JOSEPH MI
49085-8607
US

IV. Provider business mailing address

2990 NILES RD
SAINT JOSEPH MI
49085-8607
US

V. Phone/Fax

Practice location:
  • Phone: 269-983-3368
  • Fax:
Mailing address:
  • Phone: 269-983-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number4301406148
License Number StateMI

VIII. Authorized Official

Name: WARREN J WHITE JR.
Title or Position: VICE PRESIDENT OF PHYSICIAN PRACTIC
Credential:
Phone: 269-983-8127