Healthcare Provider Details

I. General information

NPI: 1639134158
Provider Name (Legal Business Name): LAKE REGIONAL MEDICAL MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

IV. Provider business mailing address

PO BOX 801661
KANSAS CITY MO
64180-1661
US

V. Phone/Fax

Practice location:
  • Phone: 573-348-8074
  • Fax: 573-348-8069
Mailing address:
  • Phone: 573-348-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN MCROBERTS
Title or Position: CEO
Credential:
Phone: 573-348-8756