Provider Demographics
NPI:1144866310
Name:LAKELAND IMMEDIATE CARE CENTER
Entity type:Organization
Organization Name:LAKELAND IMMEDIATE CARE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-357-1322
Mailing Address - Street 1:1951 OAK ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-3738
Mailing Address - Country:US
Mailing Address - Phone:269-262-4749
Mailing Address - Fax:
Practice Address - Street 1:1951 OAK ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3738
Practice Address - Country:US
Practice Address - Phone:269-262-4749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKELAND IMMEDIATE CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-22
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1144866310Medicaid