MEDICARE: LAKE GIRL, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	138512	MO

General Provider Information

NPI Number	:	1255730446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE GIRL, INC

Provider Business Mailing Address
First Line	:	4581 GRAVOIS RD
Second Line	:
City	:	HOUSE SPRINGS
State	:	MO
Zip	:	63051-1374
Country	:	US
Telephone Number	:	636-671-9980
Fax Number	:	636-671-9981

Provider Business Practice Location Address
First Line	:	4581 GRAVOIS RD
Second Line	:
City	:	HOUSE SPRINGS
State	:	MO
Zip	:	63051-1374
Country	:	US
Telephone Number	:	636-671-9980
Fax Number	:	636-671-9981

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. RENEE L WILLER
Credential	:	APRN
Telephone Number	:	314-322-7017

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	12/21/2023

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Directions to “LAKE GIRL, INC ” Practice Location

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