Provider Demographics
NPI:1306801212
Name:LAKE VILLAGE CLINIC PA
Entity type:Organization
Organization Name:LAKE VILLAGE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-265-5343
Mailing Address - Street 1:2918 LOUIS SESSIONS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-6049
Mailing Address - Country:US
Mailing Address - Phone:870-265-5343
Mailing Address - Fax:870-265-5686
Practice Address - Street 1:2918 LOUIS SESSIONS ST
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-6049
Practice Address - Country:US
Practice Address - Phone:870-265-5343
Practice Address - Fax:870-265-5686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0189208D00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101409002Medicaid
AR127181729Medicaid
AR043838Medicare Oscar/Certification
AR101409002Medicaid