Healthcare Provider Details

I. General information

NPI: 1679074470
Provider Name (Legal Business Name): LAKELAND MEDICAL PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NILES RD STE 9
SAINT JOSEPH MI
49085-3268
US

IV. Provider business mailing address

2500 NILES RD STE 9
SAINT JOSEPH MI
49085-3268
US

V. Phone/Fax

Practice location:
  • Phone: 269-408-1115
  • Fax: 269-408-1166
Mailing address:
  • Phone: 269-408-1115
  • Fax: 269-408-1166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MORGAN VINCENT
Title or Position: MEDICAL STAFF COORDINATOR
Credential:
Phone: 269-983-8282