Provider Demographics
NPI:1073509261
Name:LAKE COUNTY CARE CENTER, INC.
Entity type:Organization
Organization Name:LAKE COUNTY CARE CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-588-9928
Mailing Address - Street 1:600 DENMARK ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7500
Mailing Address - Country:US
Mailing Address - Phone:231-745-4648
Mailing Address - Fax:231-745-3724
Practice Address - Street 1:600 DENMARK ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7500
Practice Address - Country:US
Practice Address - Phone:231-745-4648
Practice Address - Fax:231-745-3724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2151229Medicaid
MI235499Medicare ID - Type Unspecified