Provider Demographics
NPI:1285062489
Name:LAKE HEALTH DISTRICT
Entity type:Organization
Organization Name:LAKE HEALTH DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BODELL
Authorized Official - Last Name:TVEIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-947-7307
Mailing Address - Street 1:700 SOUTH J ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1623
Mailing Address - Country:US
Mailing Address - Phone:541-947-2114
Mailing Address - Fax:541-947-8116
Practice Address - Street 1:535 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTURAS
Practice Address - State:CA
Practice Address - Zip Code:96101-4114
Practice Address - Country:US
Practice Address - Phone:530-233-2288
Practice Address - Fax:530-223-1941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0000001616207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty