Provider Demographics
NPI:1386876316
Name:LAKES AREA MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:LAKES AREA MEDICAL CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:HUFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-739-1995
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:KIMBERLING CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65686-0555
Mailing Address - Country:US
Mailing Address - Phone:417-739-1995
Mailing Address - Fax:
Practice Address - Street 1:11863 STATE HWY 13
Practice Address - Street 2:
Practice Address - City:KIMBERLING CITY
Practice Address - State:MO
Practice Address - Zip Code:65686
Practice Address - Country:US
Practice Address - Phone:417-739-1995
Practice Address - Fax:417-739-1893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-08
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268999Medicare Oscar/Certification