Provider Demographics
NPI:1215524756
Name:INNERCHANGE LAKE HOUSE, LLC
Entity type:Organization
Organization Name:INNERCHANGE LAKE HOUSE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF REVENUE CYCLE MANAGEMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-829-4060
Mailing Address - Street 1:5500 MING AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-4631
Mailing Address - Country:US
Mailing Address - Phone:661-622-4132
Mailing Address - Fax:
Practice Address - Street 1:447 LILY PAD LN
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:NC
Practice Address - Zip Code:28731-9503
Practice Address - Country:US
Practice Address - Phone:435-229-5498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251S00000XAgenciesCommunity/Behavioral Health