Healthcare Provider Details

I. General information

NPI: 1366563314
Provider Name (Legal Business Name): LAKELAND CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N6654 ROLLING MEADOWS DR
FOND DU LAC WI
54937-9471
US

IV. Provider business mailing address

N6654 ROLLING MEADOWS DR
FOND DU LAC WI
54937-9471
US

V. Phone/Fax

Practice location:
  • Phone: 920-906-5100
  • Fax:
Mailing address:
  • Phone: 920-906-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: KIM M MICKLE
Title or Position: COMPLIANCE MANAGER
Credential:
Phone: 920-906-5100