=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134233109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE REGIONAL HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1057B MEDICAL PARK DR
-----------------------------------------------------
City | OSAGE BEACH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65065-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-302-2700
-----------------------------------------------------
Fax | 573-302-2701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1560
-----------------------------------------------------
City | OSAGE BEACH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65065-1560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-302-2700
-----------------------------------------------------
Fax | 573-302-2701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | PAULA SUE LITTLETON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-348-8388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 2001028176
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------