Provider Demographics
NPI:1730179250
Name:COUNTY OF LAKE
Entity type:Organization
Organization Name:COUNTY OF LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COUNTY MAYOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MACIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-253-7382
Mailing Address - Street 1:333 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:TIPTONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38079-1212
Mailing Address - Country:US
Mailing Address - Phone:731-253-9911
Mailing Address - Fax:731-253-3229
Practice Address - Street 1:333 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:TIPTONVILLE
Practice Address - State:TN
Practice Address - Zip Code:38079-1212
Practice Address - Country:US
Practice Address - Phone:731-253-9911
Practice Address - Fax:731-253-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNEMS00000048013416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3525546Medicaid
TN21851Medicaid
TN21851Medicaid