Healthcare Provider Details

I. General information

NPI: 1730179250
Provider Name (Legal Business Name): COUNTY OF LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 KENTUCKY ST
TIPTONVILLE TN
38079-1212
US

IV. Provider business mailing address

333 KENTUCKY ST
TIPTONVILLE TN
38079-1212
US

V. Phone/Fax

Practice location:
  • Phone: 731-253-9911
  • Fax: 731-253-3229
Mailing address:
  • Phone: 731-253-9911
  • Fax: 731-253-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License NumberEMS0000004801
License Number StateTN

VIII. Authorized Official

Name: MR. MACIE M ROBERSON
Title or Position: COUNTY MAYOR
Credential:
Phone: 731-253-7382