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General NPI Number Information
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NPI Number | 1932493863
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Entity Type | Organization
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Legal Business Name | LAKELAND MEDICAL PRACTICES
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Dates
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Enumeration Date | 06/08/2011
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Last Update Date | 07/13/2012
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Provider Practice Location Address
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Address Line | 42 N SAINT JOSEPH AVE SUITE 200
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City | NILES
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State | MI
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Zip | 49120-2208
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Country | US
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Telephone | 269-684-5447
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Fax | 269-684-0256
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Provider Business Mailing Address
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Address Line | 6416 DEANS HILL RD
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City | BERRIEN CENTER
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State | MI
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Zip | 49102-9750
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Country | US
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Telephone | 269-471-7741
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Fax | 269-471-1581
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Authorized Official
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Title or Position | DIRECTOR, PRACTICE OPERATIONS
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Name | JANCIE CROCKER
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Credential |
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Telephone | 268-687-1152
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 4301036136
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License Number State | MI
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