Healthcare Provider Details

I. General information

NPI: 1699778233
Provider Name (Legal Business Name): THE LAKES COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15397 STATE HIGHWAY 32
LAKEWOOD WI
54138-9702
US

IV. Provider business mailing address

PO BOX 179
LAKEWOOD WI
54138-0179
US

V. Phone/Fax

Practice location:
  • Phone: 715-276-6321
  • Fax: 715-276-1428
Mailing address:
  • Phone: 715-276-6321
  • Fax: 715-276-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number4757-800
License Number StateWI

VIII. Authorized Official

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