Provider Demographics
NPI:1902462682
Name:LAKELAND MEDICAL PRACTICES
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8282
Mailing Address - Street 1:3950 HOLLYWOOD RD STE 270
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9158
Mailing Address - Country:US
Mailing Address - Phone:269-982-7840
Mailing Address - Fax:269-982-7843
Practice Address - Street 1:3950 HOLLYWOOD RD STE 270
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9158
Practice Address - Country:US
Practice Address - Phone:269-982-7840
Practice Address - Fax:269-982-7843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKELAND MEDICAL PRACTICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty