Healthcare Provider Details

I. General information

NPI: 1750878542
Provider Name (Legal Business Name): THE LAKES COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MAIN ST
BIRCHWOOD WI
54817
US

IV. Provider business mailing address

15954 RIVERS EDGE DR STE 304
HAYWARD WI
54843-7894
US

V. Phone/Fax

Practice location:
  • Phone: 715-354-3369
  • Fax: 715-354-7158
Mailing address:
  • Phone: 715-634-2541
  • Fax: 715-598-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: REBA RICE
Title or Position: CEO
Credential:
Phone: 715-372-5001