Healthcare Provider Details

I. General information

NPI: 1376646380
Provider Name (Legal Business Name): COUNTY OF LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N D ST SUITE 100
LAKEVIEW OR
97630-1540
US

IV. Provider business mailing address

100 N D ST SUITE 100
LAKEVIEW OR
97630-1540
US

V. Phone/Fax

Practice location:
  • Phone: 541-947-6045
  • Fax: 541-947-4563
Mailing address:
  • Phone: 541-947-6045
  • Fax: 541-947-4563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number93-60023202
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number StateOR

VIII. Authorized Official

Name: MRS. MARY L WILKIE
Title or Position: ADMINISTRATOR
Credential: RN, BSN
Phone: 541-947-6045