Healthcare Provider Details

I. General information

NPI: 1609953587
Provider Name (Legal Business Name): LAKE COUNTRY AREA AGENCY ON AGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 W DANVILLE ST
SOUTH HILL VA
23970-3501
US

IV. Provider business mailing address

1105 W DANVILLE ST
SOUTH HILL VA
23970-3501
US

V. Phone/Fax

Practice location:
  • Phone: 434-447-7661
  • Fax: 434-447-4074
Mailing address:
  • Phone: 434-447-7661
  • Fax: 434-447-4074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberADC782951
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License NumberHC0-17668
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberHC0-17668
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. GWEN HINZMAN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 434-447-7661