Healthcare Provider Details

I. General information

NPI: 1164850053
Provider Name (Legal Business Name): LAKE CITY PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 DEGRANDPRE WAY SUITE 300
PLATTSBURGH NY
12901-6451
US

IV. Provider business mailing address

16 DEGRANDPRE WAY SUITE 300
PLATTSBURGH NY
12901-6451
US

V. Phone/Fax

Practice location:
  • Phone: 518-561-8256
  • Fax:
Mailing address:
  • Phone: 518-561-8256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number210018
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number210018
License Number StateNY

VIII. Authorized Official

Name: MS. KELLEY BRAULT
Title or Position: OFFICE MANAGER
Credential:
Phone: 518-561-8256