Provider Demographics
NPI:1194992784
Name:LAKELAND PHYSICIAN CARE NETWORK
Entity type:Organization
Organization Name:LAKELAND PHYSICIAN CARE NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. OPERATIONS & FACILITY MANAGEME
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8399
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-0458
Mailing Address - Country:US
Mailing Address - Phone:269-684-0259
Mailing Address - Fax:269-684-0189
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2112
Practice Address - Country:US
Practice Address - Phone:269-684-0259
Practice Address - Fax:269-684-0189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUR FLAGS HEALTH VENTURES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty