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General NPI Number Information
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NPI Number | 1083810253
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Entity Type | Organization
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Legal Business Name | LAKE PARK CLINIC, P.C.
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Dates
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Enumeration Date | 06/25/2007
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Last Update Date | 06/13/2014
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Provider Practice Location Address
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Address Line | 1356 S LAKE PARK AVE
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City | HOBART
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State | IN
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Zip | 46342-5964
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Country | US
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Telephone | 219-942-8518
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Fax | 219-947-2751
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Provider Business Mailing Address
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Address Line | 1356 S LAKE PARK AVE
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City | HOBART
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State | IN
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Zip | 46342-5964
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Country | US
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Telephone | 219-942-8518
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Fax | 219-947-2751
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CHRISTINE JORDAN
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Credential |
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Telephone | 219-942-1422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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