Healthcare Provider Details

I. General information

NPI: 1386876316
Provider Name (Legal Business Name): LAKES AREA MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2009
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11863 STATE HWY 13
KIMBERLING CITY MO
65686
US

IV. Provider business mailing address

PO BOX 555
KIMBERLING CITY MO
65686-0555
US

V. Phone/Fax

Practice location:
  • Phone: 417-739-1995
  • Fax: 417-739-1893
Mailing address:
  • Phone: 417-739-1995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS L HUFFMAN
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 417-739-1995