Provider Demographics
NPI:1386311223
Name:LAKE REGIONAL HEALTH SYSTEM
Entity type:Organization
Organization Name:LAKE REGIONAL HEALTH SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-348-8388
Mailing Address - Street 1:PO BOX 801661
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1661
Mailing Address - Country:US
Mailing Address - Phone:573-348-8000
Mailing Address - Fax:
Practice Address - Street 1:755 COWAN DRIVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536
Practice Address - Country:US
Practice Address - Phone:417-532-2805
Practice Address - Fax:417-532-2848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-27
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO590107490Medicaid